[House Hearing, 112 Congress]
[From the U.S. Government Printing Office]
THE FEDERAL RECOVERY COORDINATION PROGRAM: FROM CONCEPT TO REALITY
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HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
MAY 13, 2011
__________
Serial No. 112-13
__________
Printed for the use of the Committee on Veterans' Affairs
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67-188 WASHINGTON : 2011
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairwoman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
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of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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May 13, 2011
Page
The Federal Recovery Coordination Program: From Concept to
Reality........................................................ 1
OPENING STATEMENTS
Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 28
Hon. Michael H. Michaud, Ranking Democratic Member............... 2
Prepared statement of Congressman Michaud.................... 28
__________
WITNESSES
U.S. Government Accountability Office, Randall B. Williamson,
Director, Health Care.......................................... 3
Prepared statement of Mr. Williamson......................... 29
U.S. Department of Veterans Affairs:
Karen Guice, M.D., MPP, Executive Director, Federal Recovery
Coordination Program......................................... 4
Prepared statement of Dr. Guice.............................. 33
Mary Ramos, Ph.D., RN, Federal Recovery Coordinator, San
Antonio, TX, Military Medical Center......................... 15
Prepared statement of Dr. Ramos.............................. 42
Karen Gillette, RN, MSN, GNP, Federal Recovery Coordinator,
Providence, RI, Department of Veterans Affairs Medical Center 17
Prepared statement of Ms. Gillette........................... 47
U.S. Department of Defense:
Robert S. Carrington, Director, Recovery Care Coordination,
Office of Wounded Warrior Care and Transition Policy......... 6
Prepared statement of Mr. Carrington......................... 38
Colonel John L. Mayer, USMC, Commanding Officer, Marine Corps
Wounded Warrior Regiment..................................... 18
Prepared statement of Colonel Mayer.......................... 49
Colonel Gregory Gadson, USA, Director, U.S. Army Wounded
Warrior Program.............................................. 19
Prepared statement of Colonel Gadson......................... 51
__________
Central Savannah River Area Wounded Warrior Care Projects,
Augusta, GA, James R. Lorraine, Executive Director............. 13
Prepared statement of James R. Lorraine...................... 40
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SUBMISSIONS FOR THE RECORD
Disabled American Veterans, Adrian Atizado, Assistant National
Legislative Director, statement................................ 54
Military Officers Association of America, statement.............. 57
Paralyzed Veterans of America, statement......................... 60
Wounded Warrior Project, statement............................... 62
THE FEDERAL RECOVERY COORDINATION PROGRAM: FROM CONCEPT TO REALITY
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FRIDAY, MAY 13, 2011
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 11:24 a.m., in
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[Chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle, Runyan, Michaud, and
Reyes.
OPENING STATEMENT OF CHAIRWOMAN BUERKLE
Ms. Buerkle. Good morning. Please let me begin by
apologizing for having you all wait here for the last hour and
a half. We had votes and we just finished that series of votes.
My sincere apologies for the delay.
I first of all want to thank all of you for being here this
morning as we begin to examine the Federal Recovery
Coordination Program (FRCP): From Concept to Reality.
I am Ann Marie Buerkle and I am the Chairwoman of the
Subcommittee on Health for the House Committee on Veterans'
Affairs.
Before we begin, I would like to first of all acknowledge
all of the military that we have in our audience today and
participating in our hearing. And I ask all of us to remember
our active-duty men and women who are serving our Nation. To
all of the veterans and to those who gave the ultimate
sacrifice, we must never forget what our military has done for
this Nation.
This is the greatest Nation in the history of mankind and
it is because of the service and the sacrifice of our military.
So as we enjoy the freedom today to sit here and be assembled,
we must always be aware and remember those who have served and
are serving as we speak. Thank you.
The Federal Recovery Coordination Program was the
brainchild of the Commission of Care for America's Returning
Wounded Warriors, commonly known as the Dole-Shalala
Commission.
The Commission, which was established in 2007, rightly
recognized that navigating the complex maze of the U.S.
Department of Defense (DoD) and the U.S. Department of Veterans
Affairs (VA) care, benefits, and services can be a task of
almost herculean effort for wounded warriors and their families
at a time when all of their energies and focus should be on
recovery.
The Commission recommended that we swiftly develop a
program to establish a single point of contact for wounded
warriors and their families that would make the systems more
manageable, eliminate delays and gaps in treatment and
services, and break through VA and DoD jurisdictional
boundaries to ensure a truly seamless transition.
However, almost 4 years since DoD and VA signed a
memorandum of understanding to establish the Federal Recovery
Coordination Program, significant challenges persist in areas
as fundamental as identifying potential enrollees, reviewing
enrollment decisions, determining staffing needs, defining and
managing caseloads, and making placement decisions.
Further, it appears that rather than having the joint
program envisioned by the Commission to advocate on behalf of
the wounded warriors and ensure a comprehensive and seamless
rehabilitation, recovery, and transition, we have two separate
programs--a VA program that utilizes Federal Recovery
Coordinators (FRCs) and a DoD program that utilizes Recovery
Care Coordinators (RCCs).
The intent was to streamline. The intent was to simplify.
The intent was to serve the most seriously wounded, ill, and
injured. But instead, there is duplication, there is
bureaucracy, and there is confusion.
This is unacceptable for any program that accepts tax
dollars and taxpayer funding, but it is unforgivable in a
program that serves our most severely-wounded servicemembers,
veterans, and their families.
I look forward to hearing from each of today's witnesses
how they are going to solve these problems.
At this time, I would like to recognize our Ranking Member,
Mr. Michaud, for any comments he might have.
[The prepared statement of Chairwoman Buerkle appears on
p. 28.]
OPENING STATEMENT OF HON. MICHAEL H. MICHAUD
Mr. Michaud. I want to thank you, Madam Chair, for having
this very important hearing today. It certainly is important
and an appropriate topic for this Subcommittee to hear.
And because of the votes this morning, I would ask
unanimous consent that my full opening statement be submitted
for the record so we can get on and hear the panelists.
[The prepared statement of Congressman Michaud appears on
p. 28.]
Ms. Buerkle. Thank you, Mr. Michaud.
I would like to now welcome the first panel to our witness
table. With us this morning are Mr. Randall Williamson who is
the Director of the Health Care Team for the U.S. Government
Accountability Office (GAO); Dr. Karen Guice, the Executive
Director of the Federal Recovery Coordination Program for the
Department of Veterans Affairs; and Mr. Robert Carrington,
Director, Recovery Care Coordination for the Department of
Defense, Office of Wounded Warrior and Transition Policy.
Thank you all very much for joining us this morning. And,
again, I apologize for the delay. I am very much looking
forward to our discussion.
So, Mr. Williamson, without further delay, we will start
with you.
STATEMENTS OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; KAREN GUICE, M.D., MPP,
EXECUTIVE DIRECTOR, FEDERAL RECOVERY COORDINATION PROGRAM, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND ROBERT S. CARRINGTON,
DIRECTOR, RECOVERY CARE COORDINATION, OFFICE OF WOUNDED WARRIOR
CARE AND TRANSITION POLICY, U.S. DEPARTMENT OF DEFENSE
STATEMENT OF RANDALL B. WILLIAMSON
Mr. Williamson. Thank you, Chairwoman Buerkle, Ranking
Member Michaud, and Members of the Subcommittee.
I am pleased to be here today to discuss GAO's recent
report on the Federal Recovery Coordination Program, which aims
to improve the continuity of care of severely-wounded, ill, or
injured servicemembers and veterans including those who have
suffered traumatic brain injuries (TBIs), amputations, burns,
spinal cord injuries, and post-traumatic stress.
While administered by the VA, it is designed to be a joint
DoD and VA program. Currently the FRCP employs 22 recovery
coordinators called FRCs in 12 locations nationwide and is
serving over 700 active enrollees.
Our report focused on challenges the program faces in
identifying and enrolling those who need FRCP services,
staffing and placement issues, and coordinating care for its
clients.
Regarding the first challenge, we found that it is not
clear whether all those who could benefit from the program are
being identified and enrolled in the FRCP. Because VA and DoD
lack data that specifically designates servicemembers as
severely wounded, FRCs have no systematic method to identify
potential candidates for the program.
Instead, FRCs must rely largely on referrals from
clinicians and caseworkers and other programs. But this method
isn't perfect because staff from other programs are often
unclear about the eligibility criteria for the FRCP and because
close cooperation and collaboration among the FRCP and other
wounded warrior programs is sometimes missing. This in turn can
affect the ability and willingness of other programs to refer
servicemembers to FRCs.
We also have recommended that FRCP strengthen its
enrollment, workload management, and placement processes to
best service its clients.
Most pressing, however, is the need to improve
collaboration and coordination among wounded warrior programs.
Currently FRCs face daunting challenges coordinating with a
large number of DoD and VA programs that support wounded
servicemembers and veterans.
For example, 84 percent of FRC enrollees are also enrolled
in a military wounded warrior program. Coordination among these
programs is paramount to minimize overlap, optimize information
sharing, and prevent confusion among clients and their
families.
However, we found that considerable overlap does occur
along with conflicting recovery plans on occasion. This adds to
confusion among servicemembers and their families and it is
just not in the best interest of a recovering servicemember.
We found that problems with cooperation and collaboration
occur for numerous reasons. For one, there are significant
cultural differences between VA and DoD organizations. While
the FRCP is a joint program, it is widely perceived as part of
VA.
A recurring theme, therefore, as we talk with military
staff in other programs was we can take care of our own while
they are recovering on active duty. We do not need the VA
involved.
Second, VA and DoD programs often cannot easily share
information among themselves leading to duplication of effort
and conflicting servicemember recovery goals among programs.
This occurs largely due to IT issues that limit the transparent
exchange of information between VA and DoD programs.
Third, the point at which FRCs should become involved with
a severely-wounded servicemember is blurred. Some in DoD would
say that FRCs should not be involved until it is determined
that the servicemember will likely be discharged. Conversely,
FRCs contend that they should be engaged long before that to
build rapport and trust with their clients and their families
through the continuum of care.
Finally, the primary point of contact once people are
enrolled in the FRCP is ill defined. Case managers in military
service programs often think they should be the point of
contact while FRCs think they serve this role. This has
prompted some recovering servicemembers to say I need a case
manager to manage my case managers.
In summary, while we offer ways to strengthen the
management of the FRCP, the most pressing problem is improving
the level of coordination and collaboration among the large
number of DoD and VA programs that serve our wounded warriors.
Achieving this will require efforts far beyond just what
the FRCP can achieve by itself. In the end, without cooperation
from the military services, the FRCP cannot function as
intended. This dilutes the program's ability to best serve our
wounded, ill, and injured servicemembers and veterans.
That concludes my opening remarks.
[The prepared statement of Mr. Williamson appears on p. 29.]
Ms. Buerkle. Thank you, Mr. Williamson.
Dr. Guice.
STATEMENT OF KAREN GUICE, M.D., MPP
Dr. Guice. Good morning, Chairwoman Buerkle and Ranking
Member Michaud and Members of the Subcommittee.
I request that my written statement be submitted for the
record.
The many investigations that followed the 2007 Washington
Post article on Walter Reed raised concerns about the multiple
transitions our wounded, ill, or injured servicemembers make as
they recover from war zone to inpatient care, from one hospital
to another, from a DoD facility to a VA polytrauma center, from
inpatient to outpatient, and from a military career to veteran
status.
Each transition came with multiple providers and serial
hand-offs. System navigation was left to the patient and family
who were trying to adjust to the consequences of illness or
injury. Access to accurate and timely information was difficult
and, if available, often confusing. Perceived and real system
barriers prevented access to entitlements.
These observations led to the care coordination concept in
order to create seamless synchronization of benefits and care
as these servicemembers navigated our complex systems
regardless of whether they returned to active duty or became a
veteran. The Senior Oversight Committee (SOC) created FRCP to
carry out this function.
VA agreed with all four GAO recommendations and I will tell
you the steps we have taken to address each one.
The first recommendation called for adequate internal
controls to ensure appropriate referral. As an interim
solution, FRCs discuss all enrollment decisions with management
and each decision is carefully documented.
Our permanent solution is to include an eligibility
protocol as we develop our intensity measurement tool.
FRCP does not have visibility of all who might be eligible.
As a voluntary referral program, we rely on outreach activities
and demonstrated outcomes.
FRCP conducted almost 200 outreach activities over the past
2 years. We will exceed our target this year by 25 percent.
Last year, the FRCP conducted a look-back project to
identify veterans who might still benefit from care
coordination. Through this process, we identified 35
individuals who needed further evaluation and of those, six
were subsequently enrolled.
GAO recommended that FRCP should complete development of a
workload assessment tool. Care coordination as implemented
across and within Federal agencies by FRCP is a new concept. No
guidelines or tools exist to accurately determine and balance a
range of cases for this new function. We are developing our
intensity measurement tool which will estimate the time and
effort FRCs use to coordinate services for clients based on
client attributes.
GAO recommended that FRCP should better document hiring
decisions. Given the uncertainty about the number of
individuals who might need FRCs, we have pursued a scalable
resource model based on the number of referrals, the rate of
enrollment, and the number of clients made inactive.
Once we complete the intensity measurement tool, we will
substitute allowable average intensity points for the current
benchmark range.
GAO's final recommendation was that FRCP should develop and
document a rationale for FRC placement. Initially FRCs were
placed within military treatment facilities where significant
numbers of wounded, ill, or injured servicemembers were
located. As the program grows, we consider alternative
locations.
FRC placement is guided by four factors: Replacement for
FRCs who leave the program; supplementation of existing FRCs
based on documented need; the creation of a national FRCP
network to optimize coordination; and specific requests for
FRCs in order to better serve the wounded, ill, and injured
servicemembers and veterans.
Over the next 6 months, FRCP will develop a placement
strategy based on a systematic analysis of our data. The actual
placement of FRCs is based on a case-by-case negotiation for
support and space.
Many in DoD believe that FRCP is a redundant program,
likely because the DoD's non-clinical Recovery Coordination
Program (RCP) was modeled directly from FRCP including the
design for the comprehensive recovery plan.
Others, specifically the military services wounded warrior
programs, say that FRCs should only provide support for
veterans because they are not in the military services' chain
of command.
There is no shortage of military and VA programs to support
servicemembers and veterans, so many, in fact, that our
wounded, ill, and injured servicemembers, veterans, and their
families are still confused by the number and types of case
managers as well as by benefit eligibility criteria.
FRCP was to be the single point of contact for these
individuals through care and recovery, a single point of
contact that would help them understand the complexities of
medical care provided and the array of benefits and services
available to assist recovery.
Our families and clients tell us that the program works
best when FRCs are included early in the servicemember's
recovery and prior to the first transition, whether that
transition is from inpatient to outpatient or from one facility
to another.
A single FRC stays with the client throughout all
subsequent transitions, coordinating benefits and services as
needed. This consistency is important for individuals with
severe and complex conditions who require multiple DoD, VA, and
private health providers and services.
FRCs remain in contact with their clients as long as they
are needed, whether for a lifetime or for a few weeks. FRCs'
involvement is voluntary and collaborative.
In closing, we understand that program evaluation, whether
by Congress or by an investigative body such as GAO, is a vital
part of program growth and maturation. We are grateful to GAO
for their comprehensive review of the program and to the
Members for this opportunity to discuss our continued
challenges.
Thank you and we look forward to your questions.
[The prepared statement of Dr. Guice appears on p. 33.]
Ms. Buerkle. Thank you, Dr. Guice.
Mr. Carrington, you may proceed.
STATEMENT OF ROBERT S. CARRINGTON
Mr. Carrington. Good morning, Chairwoman Buerkle, Ranking
Member Michaud, and Members of the Subcommittee.
Thank you for the opportunity to be here this morning with
Dr. Karen Guice from the VA and Randall Williamson from the
GAO.
Also joining me today from the Department of Defense are
two of my Wounded Warrior Program leads, Colonel Mayer from the
Marine Corps Wounded Warrior Regiment and Colonel Gadson from
the Army's Wounded Warrior Program.
I am pleased to discuss the role the Department of Defense
in the VA's Federal Recovery Coordination Program or FRCP.
While the FRCP was jointly developed in 2007 by DoD and VA
leaders on the Senior Oversight Committee or SOC, the program
itself continues to be solely administered and run by the VA.
DoD operates the Recovery Coordination Program or RCP which
was established later by Section 1611 of fiscal year 2008
National Defense Authorization Act (NDAA).
This program, which is actually run by the services, uses
DoD trained recovery care coordinators or RCCs who focus on the
non-medical care coordination issues of our recovering
servicemembers and their families.
They accomplish this by being an integral part of the
recovery team, by being the central point of coordination to
help ensure all needs are met, by establishing a personal
relationship and using a comprehensive recovery plan in order
to guide and focus the servicemember through all phases of
recovery, rehabilitation, and reintegration.
Within DoD, there are 146 RCCs and 170 advocates. Advocates
are what the Army calls their RCCs, all of whom are placed in
locations to best support the respective service wounded
warrior programs.
FRCs and RCCs serve similar functions but for different
categories of wounded, ill, or injured servicemembers. RCCs are
there from day one working as part of the individual service's
Wounded Warrior Program team for all servicemembers regardless
of their injury or illness. And FRCs' main focus is on
servicemembers who have severe or catastrophic injuries or
illness and are unlikely to return to duty and are likely to be
medically separated.
Practice has shown the services when, where, and how to
best bring the FRC on to their recovery teams in order to
transition the focus of the servicemember from being on active
duty to being in a veteran status.
Our DoD instruction, which follows the NDAA legislation,
directs when an FRC will be added to join with the RCC and
others to form a more complete recovery team for this category
of servicemember.
The FRC Program is effective at major military medical
treatment facilities and at VA centers. At other locations
where FRCs are not located, the services use other Veterans
Health Administration (VHA) and Veterans Benefits
Administration (VBA) liaisons and counselors to ensure that
transitioning servicemembers and their family needs are met.
As a twice deployed to both Iraq and most recently to
Afghanistan DoD civilian, I can attest to the excellent,
professional, and complete support of all my medical and non-
medical needs when I was medivacked from theater.
From my personal experience, having gone through much of
this myself and been providing this care coordination, I am
confident that our programs work and that the needs of our
wounded, ill, and injured servicemembers, their families, and
in my case a deployed government civilian are being met.
As discussed in my written statement, my office recently
completed a 2\1/2\ day wounded warrior care coordination summit
that included the chartered subgroup that focused entirely on
the collaboration between VA and DoD care coordination
programs.
Actionable recommendations from the subgroup and the other
subgroups are currently being actioned and have been presented
to the overarching integrated product team or OIPT, are
prepared to be briefed to the SOC, and will continue to be
worked until these recommendations and policies are implemented
in order ensure that best practices are implemented as we
strive for excellence across our service programs.
Also, in conjunction with the efforts of this summit, the
SOC directed RCP and FRCP leadership to establish the joint
DoD/VA Recovery Coordination Committee to identify ways to
better collaborate and coordinate the efforts of FRCs and RCCs
and to integrate FRCs where possible.
We recently concluded our second day of meetings with
representatives from across both departments and are now
finalizing our recommendations on ways to improve the use of
FRCs in the DoD Recovery Coordination Program.
Since I came on board late last year, I have already taken
actions within the DoD program in order to better integrate the
VA's FRC Program. At our DoD provided training to all RCCs, we
now include a module taught by the FRCP leadership in what FRCs
are, what they do, and how to best use their talents.
I also present a similar class in what RCCs are to the FRC
training. At our next training in June, we will also include a
lunchtime presentation from an FRC working in one of the major
hospitals about their experiences.
In conclusion, this Department is committed to working
closely with the FRCP leadership to ensure a collaborative
relationship exists between these two programs.
Madam Chairwoman, this concludes my statement. I am happy
to answer any questions. Thank you.
[The prepared statement of Mr. Carrington appears on p. 38.]
Ms. Buerkle. Thank you, Mr. Carrington.
I will now yield myself 5 minutes for questions. I will
begin with Mr. Williamson and with a general comment.
It seems pretty clear to me that the intent of this program
was to get DoD and VA together and form a single point of
contact to assist the wounded warrior in his or her pursuit of
services and care. What I hear this morning is that we still
have silos after 4 years.
My first question is to you, Mr. Williamson. If we are
looking at an integrated program, why were these
recommendations just directed at the VA rather than looking at
the big picture?
Mr. Williamson. Madam Chair, the VA administers the program
and as such, Dr. Guice reports to the Secretary and the
Secretary has the authority to take any action. So normally
always when that happens, we always address our recommendations
to the Secretary that can actually act on them.
Ms. Buerkle. I hear what you are saying, but you mentioned
that the VA administers the program. So it appears that,
whether it is reality or perception, that this is the VA's
problem and this is the VA's program.
How can we integrate DoD into your recommendations? Is it
possible?
Mr. Williamson. I think that we are in the process of doing
additional work, which will encompass all wounded warrior
programs. And at that time, we will have, I am sure, some
recommendations in that regard.
I think that even though we do not have a recommendation
focused strictly at DoD, I hope they have heard the need for
all wounded warrior programs to work together, you know, play
well in the same sandbox.
Ms. Buerkle. Thank you.
If you could provide us with what you are going to be
working on and the recommendations as well as a time frame for
when these will be accomplished----
Mr. Williamson. Very good.
[The Subcommittee staff received the information from GAO.]
Ms. Buerkle [continuing]. I would appreciate it. Thank you.
Dr. Guice, you mentioned in your testimony that the GAO
recommended systematic oversight of enrollment decisions,
complete development of a workload assessment tool, documented
staffing decisions, and the development of a rationale for FRC
placement. You mentioned that these were all in the works.
Can you give us a time frame in which these four
recommendations will be implemented?
Dr. Guice. Probably the best time frame for all of them to
be completed will be probably a year. The most critical and the
most labor intensive of the solutions is development of our
intensity tool.
Because FRCs do a very unique job, this one of care
coordination, and the needs of the individuals that they deal
with vary over time and should vary over time and we hope
diminish over time, their involvement with the clients will
match that variation and that intensity of need.
We just really do not have any way to accurately kind of
account for that at the present time. We are in the process of
developing this tool that we will use to create, rather than a
typical caseload, you know, 1 to 4 or 1 to 20 or 1 to 200
ratio, it will actually be based on points.
So the intensity of the need of the client is really what
drives the FRCs' interaction and time. And if we convert the
traditional caseload management into something else, we think
it will be a better fit for what this program does over a long
period of time for each of its clients.
That said, an assessment tool is a fairly cumbersome thing
to do and it needs validity testing and reliability testing and
integrated reliability.
We are in the process of doing that. We had FRCs come to
town and spend a couple of days. We have been doing it kind of
iteratively over the entire time that I have been here and,
again, assessing that wealth of data that we need in order to
actually create this.
So we think that we will probably have that which would be
the final piece to comply with all of the recommendations. In
the meantime, we continue to work. We have an equation now for
staffing needs, which is based on the data elements that I put
into my written statement. We are working on our placement
strategy.
We have now collected data in our data management system
about exactly where our clients are, where they live, and where
our referrals come from so that we can kind of look and match
need. We also know that there is a need to put FRCs at
polytraumas and we are currently recruiting three additional
full-time equivalent FRCs to add to our portfolio of 25--to
bring our portfolio up to 25.
Ms. Buerkle. My time is running out and I will be yielding
to the Ranking Member, but I would say that this need has been
identified since 2007 and I am hearing now today this morning
that it is going to take another year.
And my question is, and hopefully I will have another
opportunity to question this panel, what have you been doing
since 2007 that now 4 years later we are hearing it is going to
take another year?
Dr. Guice. Well, in 2007 was when the program was actually
given its operational parameters. The program actually really
did not start until 2008 and as the program has grown--when I
came close to 3 years ago, we only had 97 clients and seven
FRCs. I think part of this is growing the portfolio of
information to understand what drives the involvement of FRCs
so that we can better balance the caseloads and the work that
they need to do for that client.
They are not case managers and it is a different paradigm.
It is a pure coordination function and there just are not any
tools to actually help us. And part of it was building the
knowledge about what it takes, what drives the FRCs' time, and
we can only get that with a little bit of time to actually
understand, you know, if someone has a need for a TBI
assistance program, you know, all the pieces that have to fit
into getting that resource and aligning that with what the
client needs. And we just needed the time to develop that
information base.
Ms. Buerkle. Thank you, Dr. Guice.
I would now yield to the Ranking Member.
Mr. Michaud. Thank you very much, Madam Chair.
This is for GAO. What do you think the number one barrier
is to fixing the problems that you identify in the report?
Mr. Williamson. That is a tough one. I think breaking down
the culture within DoD and VA so that they can play and can
collaborate well, they can cooperate. That probably is the
single most important thing.
Mr. Michaud. And for the VA and DoD, what do you think it
will take to break down that barrier, the culture that has been
instilled in both agencies?
Mr. Carrington. Quite frankly, we are more than willing to
have a joint program. And our services that run these programs
reach out to the available VA representatives that can help
them take better care of their wounded, ill, and injured and
their family members.
Right now there are two separate programs and I think our
services would tell you in short give us those FRCs, let us
include them on our team, let us be responsible for them, let
us put them under our leadership, let's have them focus on
accomplishing our larger mission, and we would see probably
more success than what the GAO reported.
Dr. Guice. For me, the answer would have been if I had been
given the task to create a joint program, I would not have put
it in either department. I would have put it somewhere in
between with joint ownership by both departments which includes
joint funding.
I think if you do not have that cooperation and level of
side by side so that you are working the issues every day, you
are working the challenges every day, and you have a uniting
place where those dialogues and that function can occur, having
it isolated in either department just will not work.
I think if you look back to the Dole-Shalala Commission and
now having this experience and look at their recommendation,
they actually said put it with the Public Health Service. They
said do not put it in either house. It will then become one or
the other. It will not be joint.
And so that was their recommendation. For a lot of reasons,
that did not happen. And I think looking back on it, putting it
in a joint space is more appropriate for what we are trying to
achieve with all of this activity and programs.
Mr. Michaud. So for everyone on the panel, do you think
that the FRCPs and the RCP programs can be combined and still
be effective? And if the programs are combined, what would have
to change in order to do that?
Dr. Guice. I think that people would have to sit down and
talk about that. How does that change the current business
model for FRCP? It would not be the same program as it is
today. It would change a bit.
The same thing for the Recovery Coordination Program and
how it is currently operationalized. I think you would have to
talk about how you are going to govern this, who is going to
be, you know, sort of--how does the staffing work. It would
take a lot of work, but I do not think that is an impossible
task, sir. I think a few people and working it hard and truly
trying to understand it could come up with a solution that
might be workable.
Mr. Williamson. I think also it may go beyond just the FRCP
and the RCC. I think 4 years now after the Walter Reed
situation, there have been a lot of resources thrown at helping
the servicemember, wounded, ill, and injured servicemembers.
And there are now over ten major wounded warrior programs. And
I think it is time to step back and have an impartial look at
this.
Given the culture differences among DoD and VA or between
DoD and the VA, I am just not sure you are going to get that
kind of impartialness.
Mr. Michaud. And, DoD, you want to comment on that?
Mr. Carrington. I think services run their own unique
programs based on their culture, philosophy, size of the
population they are taking care of, and the ultimate goals of
their wounded warriors and their families. And I think that
should continue. I think we should recognize the goodness in
that.
I also believe that services do a very good job of their
programs. They could do a better job as I described if we could
better include the FRC into that team. We are already using
their resources at some locations. Other locations use VBA, VHA
resources. We agree that it is a team approach, the recovery
team, but that takes care of all the needs medical and non-
medical for the recovering servicemember.
Mr. Michaud. Great. My last question for the VA is, are you
experiencing a high turnover rate of FRCs and, if so, do you
think that hurts the program as well?
Dr. Guice. Since I have been the Executive Director, I
believe we have had two individuals, three individuals leave
the program. That is over a period of 3 years. There was some
turnover in the first 6 months of the program and that was, I
think, people trying to figure out what the role was and then
figuring out their skill set and their interests aligned with
that.
We currently have three slots that are open and we never
have a shortage of applicants. I think the program has become
recognized as a very unique and interesting place to work with
a very deserving population of seriously-wounded, ill, and
injured servicemembers that people want to be part of that.
The three that have left since I have been here have been
for personal reasons. One retired after 30 years in the VA.
Another one had some family issues that had to take care of.
Another one left for a different job opportunity that she was
interested in.
Mr. Michaud. Thank you.
Thank you, Madam Chairman.
Ms. Buerkle. Thank you, Mr. Michaud.
At this time, I would like to thank the three panel members
for testifying here this morning.
We will have another hearing within the next few months in
order to follow-up on this. I think that the intent of this was
to help the wounded warriors when they are injured and when
they come back home and need help to navigate through the
system.
Time is of the essence. They need our help now. They do not
need it a year from now or 6 months from now. So I think we
really need to approach this more urgently. We do not have the
luxury of just waiting months and months in order to help our
veterans.
So with that, I thank you all very much, and I would invite
the second panel to the table.
Thank you all very much and welcome. Again, my apologies
for the delay this morning. I apologize that you had to sit
here and wait.
Joining us on our second panel is Mr. James Lorraine, the
Executive Director of the Central Savannah River Area Wounded
Warrior Care Project. Prior to his position there, Mr. Lorraine
worked with the U.S. Special Operations Command Care Coalition.
Mr. Lorraine, thank you for joining us.
We are also fortunate to have two Federal Recovery
Coordinators with us today to explain their work, Dr. Mary
Ramos who is currently stationed at the San Antonio, TX,
Military Medical Center and Ms. Karen Gillette who is currently
stationed at the Providence VA Medical Center in Providence,
Rhode Island.
Also on the panel is Colonel Gregory Gadson, the Director
of the United States Army Wounded Warrior Care Program, and
Colonel John Mayer, the Commanding Officer of the Marine Corps
Wounded Warrior Regiment.
Gentlemen, thank you very much for your service to this
Nation and for being here this morning.
Colonel Mayer, I understand that your family is here in our
audience.
Colonel Mayer. Yes, ma'am.
Ms. Buerkle. If we could ask them to stand, we would like
to recognize them.
Colonel Mayer. They are sleeping.
Ms. Buerkle. I hope that is not a commentary on our
proceedings.
Thank you all very much for being here this morning.
Mr. Lorraine, we are going to start with you, please.
STATEMENTS OF JAMES R. LORRAINE, EXECUTIVE DIRECTOR, CENTRAL
SAVANNAH RIVER AREA WOUNDED WARRIOR CARE PROJECTS, AUGUSTA, GA;
MARY RAMOS, PH.D., RN, FEDERAL RECOVERY COORDINATOR, SAN
ANTONIO, TX, MILITARY MEDICAL CENTER, U.S. DEPARTMENT OF
VETERANS AFFAIRS; KAREN GILLETTE, RN, MSN, GNP, FEDERAL
RECOVERY COORDINATOR, PROVIDENCE, RI, DEPARTMENT OF VETERANS
AFFAIRS MEDICAL CENTER, U.S. DEPARTMENT OF VETERANS AFFAIRS;
COLONEL JOHN L. MAYER, USMC, COMMANDING OFFICER, MARINE CORPS
WOUNDED WARRIOR REGIMENT, U.S. DEPARTMENT OF DEFENSE; AND
COLONEL GREGORY GADSON, USA, DIRECTOR, U.S. ARMY WOUNDED
WARRIOR PROGRAM, U.S. DEPARTMENT OF
DEFENSE
STATEMENT OF JAMES R. LORRAINE
Mr. Lorraine. Thank you, ma'am.
Chairwoman Buerkle, Representative Michaud, distinguished
Members of the Committee, thank you for the opportunity to
speak with you today about the Federal Recovery Coordination
Program.
I would like to ask that my written statement be submitted
for the record.
Ms. Buerkle. So ordered.
Mr. Lorraine. I would like to thank the Committee for its
continuing efforts to support servicemembers and veterans and
their families as they navigate through the complex web of
government and non-government programs.
I have been a member of the military community my entire
life, a Reservist, active-duty servicemember, military spouse,
retiree, government civilian, and veteran.
In my previous position as the Founding Director of the
United States Special Operations Command Care Coalition, an
organization which advocates for over 4,000 wounded, ill, or
injured special operations forces and has been recognized as
the gold standard of non-clinical care management, I recognized
a gap in my advocacy capabilities and incorporated a Federal
recovery coordinator as a team member.
This one Federal recovery coordinator dramatically improved
how Special Operations provides transition care coordination
and made my staff more efficient, more effective in support of
the wounded warriors and our families throughout the Nation.
It is essential that our military and veterans have strong
advocates both government and non-government working together.
One program by itself is not enough when it comes to supporting
these heroes.
I recently left government service to assume duties as the
Executive Director of the Central Savannah River Area Wounded
Warrior Care Project where my current position is to integrate
services by strengthening community-based organizations that
maximize the potential of government and non-government
programs in Augusta, Georgia, and throughout the region. The
Federal Recovery Coordination Program is one of these
resources.
From my experience, care coordinators require three
attributes in order to be successful: The ability to anticipate
needs; the authority to act; and the access to work as a team
member.
The first attribute, the ability to anticipate need, is
much like a chess master thinking five to ten moves ahead. This
assumes effectiveness and competence in various levels of the
system.
By design, the Federal recovery coordinator has the
education credentials and experience to anticipate need by
functioning at a high level of competence.
We feel a certification program is necessary to prepare
these coordinators to engage in a broad spectrum of Federal and
local resources available in areas of not only health care but
with a focus on behavioral health, family support, and access
to benefits.
The second attribute is the authority to act. In this
complex environment of wounded warrior recovery, someone who
can not act is an obstacle. Actions must occur at a strategic
level to ensure case management is being accomplished, services
are being provided, and Veterans Affairs' resources are being
maximized in concert with government and non-government
programs.
The Federal recovery coordinator's authority should be
strengthened from what it is today and remain subordinate to
the Veterans Affairs' Central Office in order to influence
actions across the Nation. This ability is unique and should be
capitalized on by the Department of Defense service wounded
warrior programs and strengthened by the Veterans Benefits
Administration.
The last attribute is to the access to work as a team. I
believe this is the greatest challenge for the Federal Recovery
Coordination Program. It is the most complex of the three
attributes because it requires others to be inclusive, sharing
of information, trust, and a great deal of time and coordinated
and synchronized efforts.
Federal recovery coordinators must function in a strategic
coordination role working by, through, and with wounded warrior
programs while also leveraging Veterans Affairs' case managers
and benefits counselors.
Lastly, the scope of the Federal Recovery Coordination
Program should be expanded to assist not only those most severe
cases, but those in combination of family dynamics, behavioral
health issues, unemployment, homelessness where benefits
anomalies inhibit their smooth transition to civilian life.
In conclusion, we have three recommendations: Maintain a
high credentialing standard, but augment with a nationally
recognized certification; ensure coordinators have the
authority to act on needs they have identified; make certain
the Federal recovery coordinators have access to work as a team
member by incorporating them early in the recovery process.
There is currently a very positive feeling in the country
towards the service and sacrifice of military, veterans, and
their families and a desire to support them. One way to help is
to utilize existing programs, especially at the local level.
The Central Savannah River Area Wounded Warrior Care
Project stands as a model for many communities throughout the
Nation who are at the front line of helping our wounded, our
veterans come home all the way from combat to fully
reintegrated into our community.
It is important to educate the military and their families
about their transition, but it is frequently too late when the
transition has occurred and life's daily pace takes over.
Thank you for providing us the opportunity to brief before
the Committee.
[The prepared statement of Mr. Lorraine appears on p. 40.]
Ms. Buerkle. Thank you, Mr. Lorraine, and thank you for
your service to our country.
Dr. Ramos.
STATEMENT OF MARY RAMOS, PH.D., RN
Dr. Ramos. Thank you.
Good morning, Chairman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee. My name is Mary Ramos and I have
been a Federal Recovery Coordinator located at San Antonio
Military Medical Center for 3 years.
I am honored to be here today and I would like to request
my written statement be submitted for the record.
Ms. Buerkle. So ordered.
Dr. Ramos. In my position, I work hand in hand with those
who touch the lives of my wounded, ill, and injured clients in
order to facilitate the very best clinical and non-clinical
outcomes.
In explaining my role, I often say that I make sure that
life details happen so that clients can concentrate on recovery
and rehabilitation and so their families can support them as
they adjust to a ``new normal.''
A Federal recovery coordinator is the consummate team
member with a unique role in the very complex matrix of care
providers. The FRC role is one of overarching coordination. In
operational terms, that means while others have a defined
``lane,'' FRCs coordinate across ``lanes.'' We communicate with
key members of the provider and support teams and in
partnership assess whether there are interventions or bits of
information that might assist in optimizing outcomes.
There is a core of people supporting and coordinating care,
but the preparation of an FRC is unique in that we are all at
least master's prepared health care professionals with
expertise and/or resources in all of the systems touching the
recovering servicemember or veteran.
There are others with more depth of knowledge in a single
sphere, but the FRC has the background and experience to put
each interfacing system into context. We help others to gain an
understanding of how each issue has an impact on the clients
and family.
Our ultimate goal as nurses and social workers is
maximizing independence and maximizing life care skill by
providing support and education to our wounded, ill, and
injured.
FRCs at San Antonio or Brooke Army Medical Center (BAMC)
usually introduce clients to the FRCP early in the initial
hospitalization. While each client has a full complement of
care providers in this phase of high acuity, non-clinical
details can be addressed to facilitate future care and quality
of life and anticipate upcoming needs.
The FRC provides emotional support to the client and family
and interfaces with the team regularly. The most important
element the FRC contributes at the early treatment phase is the
concept of seamless, long-term clinical and non-clinical care
coordination. The FRC is a consistent person in the journey
from acute care through community reintegration.
It is true that when a client is in intensive care, he or
she is not thinking about whether or not they will want to
leave the service or whether or not they will seek funding to
attend college, but the FRC can assure the client that when
they are ready for those decisions, their FRC will be there
supporting those decisions within a close professional
relationship that has grown over time.
The key to success in our collaborative role is
communication and an understanding of the contribution of each
team member.
In the 3 years that I have been an FRC, global
understanding of the role has grown. Each working contact
increases knowledge about the program. The most effective
advertisement for the FRCP is the success each of us has every
day in working with clients. Personal contacts and professional
relationships mean that referrals are facilitated.
Each day as an FRC is an adventure in providing support
that could in all likelihood otherwise fall through the cracks
given the complexity of some of these cases. Much of what I
provide is not quantifiable and some of what I provide would
possibly not be missed by a client who did not anticipate a
sound safety net.
However, I have come to realize that an intimate
understanding of a servicemember's or veteran's perspective of
every-day life with an overlapping and possibly complicated
delivery system equips me to find that perhaps small
intervention that improves the quality of life for those who
risked everything for my freedom and for my grandchildren's
freedom.
I have never served in battle, but I am honored to bring
every minute of my personal and professional experience to bear
in caring for those who have borne the battle.
Thank you for inviting me here to testify today to discuss
our program. My colleagues and I are prepared to answer your
questions.
[The prepared statement of Dr. Ramos appears on p. 42.]
Ms. Buerkle. Thank you, Dr. Ramos.
Ms. Gillette.
STATEMENT OF KAREN GILLETTE, RN, MSN, GNP
Ms. Gillette. Good morning, Chairwoman Buerkle, Ranking
Member Michaud, and Members of the Committee.
My name is Karen Gillette and I am a Federal recovery
coordinator from Providence, Rhode Island.
Thank you for inviting me today to tell you what I do as an
FRC and to assist recovering servicemembers, veterans, and
their families as they heal and return home.
My testimony will focus on my roles and responsibilities in
service of my clients.
Thank you for allowing me to submit my written testimony
regarding my role.
I have been an FRC for 3 years. I currently have a caseload
of 55 clients. Thirteen of those clients are currently active
duty, 42 are veterans. Some of my clients have been recently
injured and are still being treated at military treatment
facilities while others are receiving care at private
rehabilitation facilities.
I have clients, now veterans, who were injured several
years ago and continue to need assistance with veterans'
benefits, case management, vocational rehabilitation benefits,
or help finding community resources.
My experience in this field stems from my clinical and
administrative experiences as a nurse practitioner and as a
nurse executive and from the extensive training, Federal
Recovery Coordination Program training and education on
veterans' benefits programs, military programs, TRICARE, Social
Security, U.S. Department of Labor programs, and VA programs.
My caseload consists of referrals from many sources.
Referrals come from VA case managers, military personnel,
caregivers, community and charitable organizations, and clients
who also refer other wounded warriors to our program.
I currently work with case managers located in over 35 VAs
across the country. We collaborate and share resources,
suggestions, and information that meet the clients' needs. I
work with VBA personnel who manage the compensation claims,
vocational rehabilitation, and fiduciary needs of my clients at
VBA sites across the country.
Beyond the VA, I work with staff at the Social Security
Administration, State disability and Medicaid case managers,
and TRICARE and military nurse case managers on a regular
basis.
I stay in close contact with the different Wounded Warrior
Program representatives and we discuss resources and options
that might be of benefit to the shared clients.
We collaborate closely and make sure that the right person
is doing what is needed and ensure that there is no duplication
of effort. I work with recovery care coordinators on some cases
that we share.
My job is to ensure that all of my clients are moving
closer to the goals that they established on their Federal
individual recovery plan.
I would like to share an example of a client that I have
worked with that is fairly typical of some of the issues we
address. I spoke with a case manager at a military treatment
facility about a new referral. This client had not used the VA
for health care and had been out of the military for 2 years.
In addition, the client's veterans' benefits monthly
special compensation had been decreased, which resulted in the
veteran having to relocate across the country to live with
family to be able to afford to live.
I reviewed the veteran's rating letter and found that the
rating decrease was possibly due to inadequate documentation
that had been provided to the rater.
I began to educate this individual and his family about our
program and to assist the veteran with collecting the necessary
documentation to support his appeals claim.
I called the Marine District Injured Support Cell (DISC) in
the area and asked him to contact this former Marine as an
additional support to the family. I connected the veteran with
a local VA care management team who then contacted the family
and this client to provide assistance.
There are many other examples that I could provide that
describe how closely I work with VA staff, VBA staff, and
military teams including the different wounded warrior programs
on a daily basis.
In conclusion, in the 3 years I have worked as a Federal
recovery coordinator, I have established rapport with most of
the stakeholders involved in moving these catastrophically ill
and injured servicemembers and veterans into a more stable and
satisfactory life situation.
I found that what appears to be a simple to resolve
situation can take multiple phone calls and e-mails to keep the
process moving forward towards resolution. It takes effective
communication with a variety of people to address my clients'
complex needs.
I provide support as relationships are established with VA
teams increasing the veteran and family's trust and willingness
to choose the VA as their health care provider.
I am proud to serve our country's veterans and
servicemembers that have sacrificed so much for our country.
Thank you for having me here today to share with you my
experiences and I look forward to your questions.
[The prepared statement of Ms. Gillette appears on p. 47.]
Ms. Buerkle. Thank you, Ms. Gillette.
Colonel Mayer.
STATEMENT OF COLONEL JOHN L. MAYER, USMC
Colonel Mayer. Good afternoon. Thank you, Chairwoman
Buerkle, Ranking Member Michaud, and distinguished Members of
the Subcommittee. It is my privilege to appear before you
today.
I also thank you for allowing my family in and I am sure
they are getting a great education from this afternoon.
As the Commanding Officer of the Marine Corps Wounded
Warrior Regiment, I am charged with ensuring the Nation's
wounded, ill, and injured Marines and their families receive
the best medical care and support possible.
These Marines and their families have made selfless
sacrifices that have resulted in life-changing events. Some are
even catastrophic. Whether wounded in combat, injured in
training, or fallen ill, these great Marines and their families
deserve the very best, the very best top-notch support to
include resources and tools they need to return to either
active duty or transition to civilian life.
This support is provided by the recovery team. The recovery
team for the Marine Corps consists of Marine section leaders,
staff sergeants in charge of their leadership and
accountability and motivation. It consists of recovery care
coordinators, which are mandated by Congress, to be the experts
in non-medical needs, and then the case managers provided by
the hospitals, whether it be Navy or Army, depending on what
hospital the current Marine is at. Together this team works to
provide the very best support.
The recovery care coordinators are an integral part of the
Marines' recovery equation because they are part of the Wounded
Warrior Regiment and work hand in hand with all the staff such
as the Federal recovery coordinators to ensure Marines not only
heal medically, but also pursue programs to improve their mind,
body, spirit, and their families.
The Marine Corps recognizes the value of the Federal
Recovery Coordination Program and the role that the Federal
recovery coordinators serve for Marines to transition at the
transition point or when they transition into becoming
veterans.
The Federal recovery coordinators also serve a valuable
complementary role to recovery care coordinators in providing
care to our catastrophically injured active-duty Marines.
Warrior care is a top priority for the Marine Corps and I
can assure the Subcommittee that we will continue to enhance
the capabilities of the Wounded Warrior Regiment to provide
added care and support to our wounded, ill, and injured
Marines.
Thank you.
[The prepared statement of Colonel Mayer appears on p. 49.]
Ms. Buerkle. Thank you, Colonel Mayer.
Colonel Gadson, you may proceed. Thank you.
STATEMENT OF COLONEL GREGORY GADSON, USA
Colonel Gadson. Good afternoon. Thank you, Chairman
Buerkle, Ranking Member Michaud, and all the Members of the
Subcommittee for inviting me here to appear today. I am honored
to be here.
As a wounded warrior myself, I wish to thank all the
Members of this Committee for their interest in the health and
welfare of our wounded, ill, and injured servicemembers and
veterans.
I would like to request my written statement be submitted
for the record.
Ms. Buerkle. So ordered.
Colonel Gadson. The lead proponent of the Army's Warrior
Care and Transition Program or WCTP is the Warrior Transition
Command under the command of Brigadier General Darryl A.
Williams.
I am the Director of the Army Wounded Warrior Program or
AW2, an activity of the Warrior Transition Command. AW2
supports severely-wounded soldiers, veterans, and family
members through their recovery and transition and even when
they separate from the Army. We do this through more than 170
AW2 advocates to provide local personalized support to more
than 8,300 soldiers, veterans currently enrolled in the
program.
The WCTP also encompasses the 29 warrior transition units
or WTUs located around the country and in Europe where wounded,
injured, and ill soldiers heal from and prepare for their
transition.
I have advocates at each of these WTUs to work with these
soldiers, families, and WTU personnel to ensure the smoothest
possible transition for soldiers.
Each soldier in a WTU is assigned a triad of care
consisting of a primary care manager, usually a physician, a
nurse case manager, and a squad leader.
In addition, the WTUs have a multi-disciplinary approach
that includes a wide range of clinical and non-clinical
professionals. AW2 advocates work closely with each of these
professionals in support of their individual soldier.
A requirement for every servicemember in the Federal
Recovery Care Program is to have a comprehensive needs
assessment or Federal individual recovery plan. This is
accomplished within the WTUs through a comprehensive training
plan or CTP wherein soldiers set long and short-term goals in
each of the six domains of life, family, social, spiritual,
emotional, career, and physical.
Families are closely involved with this CTP progress and
family is one of the six domains of goal setting in this CTP.
They are all invited to all of the focused transition review
meetings and to all medical appointments.
When at AW2 soldier separates from the Army and transitions
to veteran status, an AW2 advocate continues to support the
soldier or veteran and their family.
Another key component of the WCTP is the soldier family
assistance centers or SFAC on site at the WTUs. They bring
together many of the programs soldiers and families need to
provide assistance with everything from child care and lodging
to arranging for VA care and benefits.
The Federal Recovery Coordination Program has the potential
to facilitate positive quality integration across various
programs throughout the Federal Government and supports the
severely-wounded, injured, and ill servicemembers.
The AW2 advocates on my staff report having positive
relationships with the FRCs and indicate that the FRCs are
well-trained professionals. The FRCs are well-versed in the
resources provided by the Department of Veterans Affairs and
other resources available in their regions.
I want to discuss the GAO's recommended actions for the
FRCP. As you have read in the comment section of the GAO
report, the Honorable John Campbell, Deputy Assistant Secretary
for Defense Wounded Warrior Care and Transition Policy,
committed the Department of Defense to continuing to
collaborate with the VA on these issues.
A joint DoD/VA Committee has been formed to study how to
combine and integrate recovery coordination efforts for
wounded, injured, and ill servicemembers, veterans, and
families.
Recommendation one of the GAO report discusses establishing
adequate internal controls regarding the FRCs' enrollment
decisions. This is not a problem at AW2. While FRCs are
afforded broad discretion in determining which servicemembers
are admitted to the program, AW2 has clear eligibility criteria
with all eligibility decisions being made at the headquarters
level.
The GAO's next recommendation discusses the FRCP's efforts
to manage the workloads of individual FRCs based on the
complexity of the services needed. At AW2, we pay very close
attention to the caseloads of our AW2 advocates. The average
caseload is 1 to 50, but each soldier requires a different
level of support depending where he or she is in the recovery
and transition process.
For example, AW2 veteran Kortney Clemons, a severely-
wounded veteran, who no longer requires significant level of
support from AW2, lost his right leg above the knee. Kortney
has been out of the Army for more than 5 years. He has gone on
to become an elite level runner and is training for the
Paralympic games in London next year. He is currently enrolled
in a master's program at University of Kansas and no longer
requires the same level of support from an AW2 advocate that he
did when he was first injured.
AW2 recognizes that many soldiers and veterans we support
become more independent as they heal and transition to the next
phase of their lives. We developed a life cycle case management
plan or LCMP to help AW2 advocates identify the level of
support each soldier needs.
There are four phases. When a soldier requires a
significant level of support, AW2 calls them at least once a
month and in some cases and in many cases more. As they
progress and become more independent, we call them less
frequently. In the last case, we only call them 180 days.
I am proud to say that I am one of those that is in the
lifetime phase of our LCMP.
Soldiers and veterans can always call their AW2 advocates
or the AW call center at any time. This initiative allows AW2
advocates to focus on those with more immediate support.
The GAO's third recommendation addresses the FRCP's
decision-making process for making staffing decisions. AW2
faces the same challenges as the FRCP on this issue. It is
difficult to predict how many soldiers will qualify for our
program in the future.
In 2010, we accepted more than 2,000 soldiers into the
program. This fact makes it more important that we ensure the
AW Program runs as efficiently as possible.
The GAO's final recommendation calls for the FRCP to
develop a clear rationale for the placement of FRCs. At AW2, we
evaluate our staffing on a quarterly basis. We assign advocates
where we have the highest populations of AW2 soldiers and
veterans essentially by zip codes.
I would submit that by aligning FRCs in a similar manner
regionally would better serve both them and the servicemembers
they serve.
The GAO report also highlighted the challenges and
information sharing between DoD and VA. We recognize the
importance of this challenge. For over a year now, the Warrior
Transition Command has been developing automated systems that
are part of an integrated system for tracking and managing the
care of soldiers and veterans.
Currently being completed for implementation later this
year is the central module of this system referred to as the
Automated Warrior Care and Tracking System which contains the
history of each soldier and veteran's care.
The Executive Director of the FRCP and Deputy Under
Secretary of Defense for Wounded Warrior Care and Transition
Policy are also co-chairing an information sharing initiative
or ISI to support the coordination of non-clinical care. The
ISI will enable sharing of authoritative data electronically
between DoD, VA, and the Social Security Administration for
case and care management systems.
In closing, I thank you again, Madam Chairman and Ranking
Member Michaud, for inviting me here today and for listening to
my testimony about the Federal Recovery Coordination Program. I
appreciate your attention to wounded, injured, and ill
servicemembers and veterans and their families, and I know that
we share the same goal of providing the best possible services
to these individuals who have sacrificed so much.
Thank you and I look forward to your questions.
[The prepared statement of Colonel Gadson appears on p.
51.]
Ms. Buerkle. Thank you, Colonel Gadson.
I will now yield myself 5 minutes for questions.
We have heard from a few of the panelists today about the
need to provide our servicemen and women with top-notch care. I
think when we talk about providing quality care, we need to
provide timely care and access to services.
So I would like it if each one of you would take a few
minutes to tell me how can we fix this. What do you see? If you
could give me one way you think we can improve the coordination
and whether or not you think it is possible to coordinate the
Department of Veterans Affairs and DoD and to get the job done
for our wounded warriors, a recommendation, and whether or not
you think it is possible.
I will start with Mr. Lorraine. Thank you.
Mr. Lorraine. Thank you, Madam Chairwoman.
My recommendation would be to start where the casualties
begin and that is to integrate the Federal recovery
coordinators into the wounded warrior programs so that they can
be integral at their command level so that they can be part of
the process more as an advisor.
What we found was that a bulk of our effort while on active
duty came through the Department of Defense, but there were
veterans' issues that came along up until the time they retired
or separated the servicemembers. At that point, it became very
heavy in Veterans Affairs. DoD did not have the authority to
influence it. The FRC did. But their success was because they
were involved in it beforehand.
What we also found was while the servicemember had an
affinity towards Special Operations while they were recovering,
the more the Federal recovery coordinator assisted them after
their retirement, the more direct they came to the Federal
recovery coordinator. It was a very smooth transition.
So if there is one recommendation, it would be to integrate
the Federal recovery coordinators at the headquarters levels of
the service programs, to engage early and to provide strategic
engagement, solving problems, and directing the local folks as
needed.
Ms. Buerkle. Thank you, Mr. Lorraine.
Dr. Ramos, before you comment, are you included when the
servicemember is still in acute care and in the hospital
setting? Are you a part of the discussion at that point?
Ms. Ramos. Yes, ma'am. We have been alerted usually by the
case management team when patients are still in their initial
hospitalization that it is anticipated that they will need the
services of the FRCP and that a Federal recovery coordinator
would be advantageous as a participant in the team.
We have open access to all of the medical conferences, all
of the discussions, all of the records, and have close
communication with the care management team as well as the
providers. We also identify at that point in time who the squad
leader is and we will have discussions with the squad leader as
is appropriate.
I also have very close communication with the medical
director of our WTU, our warrior transition unit, and with the
primary care providers who actually do the medical care on an
outpatient basis.
So I have open access to everyone and they will ask me
questions. And I will participate as appropriate in the team,
although I must admit there are many cases where the
coordination is going well and what I am doing at that point in
time is establishing a relationship that is supportive of the
family so that they know that the things they are anticipating
happening in the next 2 to 3 years are going to happen with the
support of a Federal recovery coordinator at their side.
And so my usual speech includes, you know, right now your
job is to support your servicemember in recovery, to take care
of yourself, and to let me know what bumps are in the road so
that I can smooth them out for you and you can concentrate on
what is important right now.
Ms. Buerkle. Thank you, Dr. Ramos.
Ms. Gillette.
Ms. Gillette. Thank you.
I think what I would find the most beneficial, and it
sounds a little self-serving, is more FRCs around the country.
You know, we do have a heavy caseload and while I feel like I
am being very efficient, I could be a lot more efficient
because there are so many clients out there that are considered
category two that I assist, but I would really like to carry on
my caseload.
Ms. Buerkle. And in your institution in Providence, do you
have the same situation? Are you included in the acute care
setting in the discussion in the beginning of the planning?
Ms. Gillette. The clients that I have that are in an acute
care setting such as right now I have six at Walter Reed, when
they have team meetings, I know ahead of time and I can call in
and participate.
But when they are in the acute care phase, I spend a lot
more time supporting the family, preparing the family for
future planning, letting them know that when we are talking
about discharge planning, for instance, a client I have right
now in Tampa who is from Boston, working with the mother of
thinking about future planning for this young man when he comes
home to Boston because he will need a type of a TBI-assisted
living setting.
Ms. Buerkle. Thank you.
Colonel Mayer.
Colonel Mayer. Ma'am, as a commander, especially a
commander of Marines, I am in charge of everything the Marine
does and fails to do. Same with his recovery process. And so
from the beginning, we set goals and the team, the recovery
team, as I mentioned before, helps the Marine and his family
achieve those goals.
And the multi-disciplinary team meetings start right from
the beginning and they go sometimes daily at the beginning when
there is a big need and then continuing throughout his
transition and even beyond.
And the FRC plays an important part and I ask that they get
involved with the multi-disciplinary team meetings from the
beginning, but realize that the Marine, while he is on active
duty, is going to be under the responsibility of the Marine
leadership at that particular location. But they play a huge
part, a complementary part as a member of the team.
Ms. Buerkle. Thank you, Colonel.
Colonel Gadson.
Colonel Gadson. Yes, ma'am. I think what I would do is I
would kind of echo a little bit of what I said and kind of
combine with Jim and Ms. Gillette's statement and that is
establishing a uniform criteria for who will receive the
services of the FRC.
And I think that is done at the point of entry and I think
that will drive, as Ms. Gillette said, more FRCs. If we
establish a criteria, then we can predict and understand the
population that we are going to go after and serve and then
bring up the levels of FRCs that are out there.
They are powerful members of the team and have again
tremendous experience and expertise, which everyone has
demonstrated. It is just a matter of really, I think, having
them in the kind of numbers that would make a difference across
the larger force.
Ms. Buerkle. Thank you, Colonel Gadson.
Since I appear to have extra time for questions, I will
indulge myself.
If you could, would you all mind telling me what is the
most common issue that you confront with a wounded warrior? We
will start with Mr. Lorraine.
Mr. Lorraine. I think the most common issue that I confront
now are folks who fit in the cracks. They do not qualify for
the, and I will use the Army, an Army soldier, they may not
qualify for the Army Wounded Warrior Program because of the
severity of their injury. They are not severe enough to be an
FRC. They are already discharged out of the Warrior Transition
Command.
So they are a veteran who does not fall within any of the
programs that exist and they need some guidance. To get through
the system, it is sort of like handing somebody the New York
City Yellow Pages and say here you go, you can figure this out.
And most of our folks just cannot take that step to do it. It
is difficult to find out who they can trust, who will take
action. And that is really what the big thing is.
So how do you find the folks who are in the greatest need?
There is a lot of folks who slip between the cracks. That is
why I would advocate for more FRCs, but a broader--they need
one person to touch, as a veteran, one person to touch who can
access both the benefits and the health care system, that can
guide them through and shepherd them not just because of the
severity of the wound, but the economic or the social position
that they may have fallen into post service.
Ms. Buerkle. Thank you, Mr. Lorraine.
Mr. Lorraine. Yes, ma'am.
Ms. Buerkle. Dr. Ramos.
Ms. Ramos. I think the most common thing that I am having
to cope with is a client and a client's family who are frankly
totally overwhelmed. This is not a chronic condition. This is
an acute injury for the most part. This has been a surprise.
Their whole lives have been derailed.
They are coming usually to San Antonio from another place
in the country. They are trying to deal with caring for their
children, caring for their warrior, caring for themselves,
trying to coordinate communication, trying to understand what
is going on with their wounded or injured servicemember, and
they are totally overwhelmed by the health care issues, the
social issues, the logistical issues, and trying to carry on
within every-day life.
I think it would help if there were a single point of
contact, but I have to tell you that in my particular setting,
we kind of negotiate that within the team. Often there is a
great level of rapport with the special forces person or the
RCC from the Marines or the case manager who is doing the
inpatient care. Sometimes it is the Federal recovery
coordinator.
But as a team, we kind of decide who is going to be the
lead for the moment because the situation is so fluid and it
changes so quickly, we feel it is critical so that the family
member will have a point of contact.
We also need for them to have a single point of contact
because it can be very confusing if we have mom going one
place, dad going another place, and wife going another place.
So communication is the key to defusing these situations,
but I am constantly coping with people who are overwhelmed by
what is going on and feeling responsible for making sure that
they feel safe in the situation.
Ms. Buerkle. And would you say that the services that they
need to deal with their situation are available?
Ms. Ramos. Oh, totally.
Ms. Buerkle. Okay.
Ms. Ramos. Totally. I love working with my Marines. We have
the most wonderful services for our individual servicemembers.
The Navy Safe Harbor people there are wonderful. The AW2s are
unfailingly helpful. I love the Marines and, you know, the air
force people are great.
I carry clients from all four services obviously and Army
medical center, I carry mostly Army people, but as an FRC who
takes a lot of the burn patients, I have everybody because we
are the burn center. And the confusion is the difficulty, just
people being totally overwhelmed by the situation.
Ms. Buerkle. So it seems to me if the services are
available, that is the difficult part. The easy part should be
the coordination and so that really needs to be the focus
obviously for the first panel as well in order to get the
servicemembers what they need.
Ms. Ramos. I think that at my particular location, we do a
great job of that because we do talk to each other openly and
we are always in communication with the different members of
the care provision team. And we all are totally focused on the
client and the family. We just work that way. So it is very
satisfying. It is a difficult job, but it is very satisfying.
Ms. Buerkle. Thank you.
Ms. Gillette.
Ms. Gillette. Being located in the northeast, I will have
to say that the resources are not available. Many of my clients
are in very rural areas. For instance, I have 15 clients in
upstate New York. It is very difficult at times to have a young
man who had a severe TBI, wants to live at home, which is in a
rural part of New York, the VA does not provide transport--they
provide transportation into the VA but nowhere else, and he
cannot drive. And his family all works.
So when the veterans, even some of them are still active
duty but on terminal leave, get into their home setting which
is a very rural site, the resources are not there. So I spend a
lot of time working with overwhelmed families, wives, mothers
who are exhausted, trying to make sure that every VA resource
and State resource is available to them and then trying to pull
together charitable organizations, veterans' organizations to
put all the other pieces together.
Ms. Buerkle. Thank you.
Colonel Mayer.
Colonel Mayer. Yes, ma'am. For the most part, the
opportunities far exceed the demand for the various
opportunities. Most of the Marines are 18 to 25 right out of
high school, when they join the Marine Corps, went through
training, went over to the war, and then are catastrophically
injured. And so it is the overwhelming nature of now trying to
understand the Marine Corps, trying to understand the hospital
system, and trying to understand the future and setting the
goals and then sticking with the goals in the new State.
And I think that, ma'am, the coordination is there and I
think we do a super job at all the different locations, and you
heard about Brooke Army Medical Center down there, of working
at the tactical level to achieve the goals of the Marines.
Oftentimes it is too many people saying here is what we
should be doing next. And so I would say most are overwhelmed
with just trying to understand what is next and the way to go.
Ms. Buerkle. Thank you, Colonel Mayer.
Colonel Gadson.
Colonel Gadson. Yes, ma'am. I am going to echo Colonel
Mayer. As someone who lost, you know, both my legs, you are
just overwhelmed with advice, overwhelmed with input. And I
think that is still a challenge today.
And then really about the transition, I mean, as well-
intentioned as we all are about helping these folks and their
families move on, everybody has their own individual timeline
and it takes some time. And it might be 3 years, it might be 4
years before someone is ready to come back on a net and move on
with their life.
And so there can sometimes be a lot of lost ground and
those are some of the big challenges I think all the programs
face.
Thank you.
Ms. Buerkle. Thank you, Colonel Gadson.
Thank you to all of the members of the second panel for
sharing your expertise with us.
As I mentioned earlier, I would like to follow-up this
hearing with another hearing to hear how the program is
progressing and to make sure we, as a Nation, provide what our
wounded warriors need from us.
I ask unanimous consent at this time that all Members have
5 legislative days to revise and extend their remarks and
include any extraneous materials. Without objection, so
ordered.
Thank you all again. Thank you to the witnesses. Again, my
sincere apologies for the delay this morning.
And at this time, the meeting is adjourned. Thank you.
[Whereupon, at 12:49 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Ann Marie Buerkle,
Chairwoman, Subcommittee on Health
Good morning and thank you all for joining us today as we examine
``The Federal Recovery Coordination Program: From Concept to Reality.''
The Federal Recovery Coordination Program was the brain child of
the Commission on Care for America's Returning Wounded Warriors,
commonly known as the Dole-Shalala Commission.
The Commission, which was established in 2007, rightly recognized
that navigating the complex maze of Department of Defense (DoD) and
Department of Veterans Affairs (VA) care, benefits, and services can be
a task of almost Herculean effort for wounded warriors and their
families at a time when all of their energy and focus should be on
recovery.
The Commission recommended that we swiftly develop a program to
establish a single point of contact for wounded warriors and their
families to make these systems more manageable, eliminate delays and
gaps in treatment and services, and break through VA and DoD
jurisdictional boundaries to ensure a truly seamless transition.
However, almost 4 years since DoD and VA signed a memorandum of
understanding to establish the Federal Recovery Coordination Program,
significant challenges persist in areas as fundamental as identifying
potential enrollees, reviewing enrollment decisions, determining
staffing needs, defining and managing caseloads, and making placement
decisions.
Further, it appears that rather than having the joint program
envisioned by the Commission to advocate on behalf of wounded warriors
and ensure comprehensive and seamless rehabilitation, recovery, and
transition, we have two separate programs--a VA program that utilizes
Federal Recovery Coordinators and a DoD program that utilizes Recovery
Care Coordinators.
The intent was to streamline. The intent was to simplify. The
intent was to serve the most seriously wounded, ill, and injured. But,
instead, there is duplication, there is bureaucracy, there is
confusion.
This is unacceptable in any program that receives taxpayer funding.
But it is unforgivable in a program that serves our most severely
wounded servicemembers, veterans, and their families. I want to hear
from each of today's witnesses how they are going to solve these
problems.
I now recognize our Ranking Member, Mr. Michaud for any remarks he
may have.
Prepared Statement of Hon. Michael H. Michaud,
Ranking Democratic Member, Subcommittee on Health
Thank you, Madam Chair.
I would like to thank you for holding this hearing today. Certainly
this is an important and appropriate topic for this Subcommittee.
We are here today to examine the effectiveness of the Federal
Recovery Coordination Program (FRCP) and to assess if outreach has
succeeded in bringing coordinated care to veterans who were injured
prior to the FRCP. When a servicemember returns from combat we must
make every effort and direct our considerable resources to ensuring
that they and their families receive compassionate, comprehensive, and
coordinated care from the beginning. Continued oversight of this
important program is critical because if it is not done right,
servicemembers suffer.
For some time now we have heard stories of servicemembers returning
home from serving their country, with no guidance and no support. Too
often we hear of families carrying the burden of a servicemember's
recovery and reintegration back into civilian life. In addition, we
know that servicemembers experience confusion, redundancy of services,
and conflicting advice given by the many coordinators that are part of
the recovery process. I am sure you will agree that we must do better.
Challenges remain and there is still much work to be done. Although
there is a solid foundation for the FRCP, I am looking forward to not
only hearing testimony from the panelists but also having a frank
discussion on ways to fix the issues and overcome barriers. I am
confident that by working together we can do just that.
The Dole-Shalala Commission, which set out recommendations for the
care of wounded warriors, said it is not enough ``merely patching the
system, as has been done in the past. Instead, the experiences of these
young men and women have highlighted the need for fundamental changes
in care management and the disability system.'' The Commission
emphasized that significant improvements require a ``sense of urgency
and strong leadership.''
I want to take this opportunity to thank you all for your
dedication to our Nation's veterans.
Prepared Statement of Randall B. Williamson,
Director, Health Care, U.S. Government Accountability Office
FEDERAL RECOVERY COORDINATION PROGRAM: Enrollment, Staffing, and Care
Coordination Pose Significant Challenges
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
I am pleased to be here today as you discuss the challenges facing
the Federal Recovery Coordination Program (FRCP)--a program that was
jointly developed by the Departments of Defense (DoD) and Veterans
Affairs (VA) following critical media reports of deficiencies in the
provision of outpatient services at Walter Reed Army Medical Center.
This program was established to assist ``severely wounded, ill, and
injured'' Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) servicemembers, veterans, and their families with access to care,
services, and benefits.\1\ Specifically, the program's population was
to include individuals who had suffered traumatic brain injuries,
amputations, burns, spinal cord injuries, visual impairment, and post-
traumatic stress disorder. From January 2008--when FRCP enrollment
began--to May 2011, the FRCP has provided services to a total of 1,665
servicemembers and veterans; of these, 734 are currently active
enrollees.
---------------------------------------------------------------------------
\1\ OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations. Since September
1, 2010, OIF is referred to as Operation New Dawn.
---------------------------------------------------------------------------
As the first care coordination program\2\ developed collaboratively
by DoD and VA, the FRCP is more comprehensive in scope than clinical or
nonclinical case management programs. It uses Federal Recovery
Coordinators (FRC) who are either senior-level registered nurses or
licensed social workers to monitor and coordinate both the clinical and
nonclinical services needed by program enrollees by serving as a link
between case managers of multiple programs. Unlike case managers, FRCs
have planning, coordination, monitoring, and problem-resolution
responsibilities that encompass both health services and benefits
provided through DoD, VA, other Federal agencies, States, and the
private sector.
---------------------------------------------------------------------------
\2\ According to the National Coalition on Care Coordination, care
coordination is a client-centered, assessment-based interdisciplinary
approach to integrating health care and social support services in
which an individual's needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and
monitored by an identified care coordinator.
---------------------------------------------------------------------------
The FRCs' primary responsibility is to work with each enrollee
along with his or her family and clinical team to develop a Federal
Individual Recovery Plan, which sets individualized goals for recovery
and is intended to guide the enrollee through the continuum of care.\3\
As care coordinators, FRCs are generally not expected to directly
provide the services needed by enrollees. However, FRCs may provide
services directly to enrollees in certain situations, such as when they
cannot determine whether a case manager has taken care of an issue for
an FRCP enrollee, when asked to resolve complex problems, or when
making complicated arrangements.
---------------------------------------------------------------------------
\3\ The continuum of care consists of three phases: acute medical
treatment and stabilization, rehabilitation, and reintegration--either
a return to active duty or to the civilian community as a veteran.
---------------------------------------------------------------------------
The FRCP is administered by VA, and FRCs are VA employees. Since
beginning operation in January 2008, the FRCP has grown considerably
but experienced turmoil in its early stages, including turnover of
staff and management. At present, there are 22 FRCs who have been
located at various military treatment facilities, VA medical centers,
and the headquarters of two military wounded warrior programs. While
the FRCs are physically located at certain facilities, their enrollees
are scattered throughout the country and may not be receiving care at
the facility where their assigned FRC is located.
My testimony is based on our March 2011 report,\4\ which examined
several FRCP implementation issues: (1) whether servicemembers and
veterans who need FRCP services are being identified and enrolled in
the program, (2) staffing challenges confronting the FRCP, and (3)
challenges facing the FRCP in its efforts to coordinate care for
enrollees.
---------------------------------------------------------------------------
\4\ GAO, DoD and VA Health Care: Federal Recovery Coordination
Program Continues to Expand but Faces Significant Challenges, GAO-11-
250 (Washington, DC: Mar. 23, 2011).
---------------------------------------------------------------------------
To obtain information about these challenges, we conducted more
than 170 interviews of the following groups: FRCs; FRCP leadership,
which includes the Executive Director, the Deputy Director for Health,
and the Deputy Director for Benefits; leadership officials with DoD and
VA case management programs, including leadership officials from each
military service's wounded warrior program; and medical facility
directors and staff at DoD and VA medical facilities. We interviewed
the FRCs individually to learn about challenges they have encountered,
using comprehensive interviews of the 15 FRCs who were working in the
FRCP in or before December 2009 and limited interviews of the 5 FRCs
who were hired in January 2010. To develop an understanding about how
clinical and nonclinical officials and staff interact with the FRCs, we
conducted site visits and telephone interviews with program officials
at DoD and VA headquarters and medical facility staff at the DoD and VA
medical facilities where FRCs are located.\5\
---------------------------------------------------------------------------
\5\ These facilities included Walter Reed Army Medical Center;
National Naval Medical Center; Brooke Army Medical Center; Naval
Medical Center-San Diego; Naval Hospital Camp Pendleton; Eisenhower
Army Medical Center; and the VA medical centers in Houston, Texas;
Providence, Rhode Island; and Tampa, Florida. In addition, we visited
three VA medical centers with which FRCs have significant interaction--
the facilities in Richmond, Virginia; Augusta, Georgia; and San Diego,
California. At the end of calendar year 2010, following the completion
of our site visits, the FRCP placed two FRCs at the VA medical center
in Richmond.
---------------------------------------------------------------------------
We performed content analysis of the qualitative information
obtained from the FRCs, DoD and VA program officials, and medical
facility staff by grouping their responses by topic and then
identifying response patterns. Content analysis of qualitative
information obtained from DoD and VA program officials and medical
facility staff was conducted using a software package, which enabled us
to analyze responses to specific interview topics for a large number of
interviews. However, the results from our site visits and interviews
cannot be generalized because while all DoD and VA facilities could
potentially interact with FRCs, our review focused on facilities where
FRCs are located as well as some facilities where FRCs have significant
interaction. In addition, we obtained and reviewed documentation
related to the FRCP, including VA's October 2009 handbook on care
management of OEF and OIF veterans; the FRCP Standard Operating
Procedures; the FRCP fiscal year 2010 operating plan; and draft FRCP
procedures, such as the VA handbook on the FRCP.\6\
---------------------------------------------------------------------------
\6\ The FRCP Handbook was finalized on April 1, 2011.
---------------------------------------------------------------------------
We conducted the performance audit for our report from September
2009 through March 2011 and updated certain data elements in May 2011
for this testimony, in accordance with generally accepted government
auditing standards. These standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
In summary, we found that while the FRCP has overcome some early
setbacks, it currently faces challenges related to the enrollment of
potentially eligible individuals, determination of FRC staffing needs
and placement, and the FRCP's ability to coordinate care for enrollees.
Challenges in identifying potentially eligible
individuals. It is unclear whether all individuals who could benefit
from the FRCP's care coordination services are being identified and
enrolled in the program. Because neither DoD nor VA medical and
benefits information systems classify servicemembers and veterans as
``severely wounded, ill, and injured,'' FRCs cannot readily identify
potential enrollees using existing data sources. Instead, the program
must rely on referrals to identify eligible individuals. Once these
individuals are identified, FRCs must evaluate them and make their
enrollment determinations--a process that involves considerable
judgment by FRCs because of broad criteria. However, FRCP leadership
does not systematically review FRCs' enrollment decisions, and as a
result, program officials cannot ensure that referred individuals who
could benefit from the program are enrolled and, conversely, that the
individuals who are not enrolled are referred to other programs.
Challenges in determining staffing needs and placement
decisions. The FRCP faces challenges in determining staffing needs,
including managing FRCs' caseloads and deciding when VA should hire
additional FRCs and where to place them. According to the FRCP
Executive Director, appropriately balanced caseloads (size and mix) are
difficult to determine because there are no comparable criteria against
which to base caseloads for this program because of its unique care
coordination activities. The program has taken other steps to manage
FRCs' caseloads, including the use of an informal FRC-to-enrollee
ratio. Because these methods have some limitations, the FRCP is
developing a customized workload assessment tool to help balance the
size and mix of FRCs' caseloads, but it has not determined when this
tool will be completed. In addition, the FRCP has not clearly defined
or documented the processes for making staffing decisions in FRCP
policies or procedures. As a result, it is difficult to determine how
staffing decisions are made, or how these processes could be sustained
during a change in leadership. Finally, the FRCP's basis for placing
FRCs at DoD and VA facilities has changed over time, and the program
lacks a clear and consistent rationale for making these decisions,
which would help ensure that FRCs are located where they could provide
maximum benefit to current and potential enrollees.
Challenges in coordinating with other VA and DoD programs
and supporting FRCs. A key challenge facing the FRCP concerns the
coordination of services by the large number of DoD and VA programs
that support wounded servicemembers and veterans. Although these
programs vary in terms of the severity of the injuries among the
servicemembers and veterans they serve and the specific types of
services they coordinate, many programs have similar functions and are
involved in similar types of activities. Table 1 illustrates the key
characteristics of major DoD and VA programs and the activities in
which they are involved.
Table 1: Characteristics of Major Department of Defense (DoD) and Department of Veterans Affairs (VA)
Programs for Seriously and Severely Wounded Servicemembers and Veterans
----------------------------------------------------------------------------------------------------------------
Program characteristics Type of services provided
----------------------------------------------------------------------------------------------------------------
Severity Title of care
Program of coordinator Lifetime Non- Recovery
Program name description enrollees' or case follow-up Clinical clinical plan
injuriesa manager
----------------------------------------------------------------------------------------------------------------
VA/DoD Federal Recovery Joint DoD/VA Severe Federal
Coordination Program initiative that Recovery
(FRCP) coordinates Coordinator
clinical and (FRC)
nonclinical
services and
benefits across
Federal, State,
and private
entities for
recovering
servicemembers,
veterans, and
their families.
----------------------------------------------------------------------------------------------------------------
DoD Recovery DoD program that Serious Recovery Care .........
Coordination Program coordinates Coordinator
nonclinical
services and
benefits for
recovering
servicemembers.
----------------------------------------------------------------------------------------------------------------
Army Warrior Transition Army unit that Serious to Triad of
Units provides severe nurse case
complex manager,
outpatient case squad
management for leader, and
servicemembers physician
requiring more
than 6 months
of medical
treatment.
----------------------------------------------------------------------------------------------------------------
Military wounded warrior Programs Serious to Case manager .........
programsb operated by the severe or Advocate
military (title
services that varies by
help manage service)
servicemembers'
recovery
process,
including the
Army Wounded
Warrior
Program, Marine
Wounded Warrior
Regiment, Navy
Safe Harbor,
Air Force
Warrior and
Survivor Care
Program, and
Special
Operations
Command's Care
Coalition.
----------------------------------------------------------------------------------------------------------------
VA OEF/OIF Care VA program that Mild to Case manager,
Management Programc facilitates the severe Transition
transition of Patient
care from Advocated
military to VA
medical
facilities and
the
coordination of
clinical and
nonclinical
services for
OEF/OIF
servicemembers
and veterans.
----------------------------------------------------------------------------------------------------------------
VA Spinal Cord Injury VA system of Mild to Nurse, social
and Disorders Program care that severe worker
provides a
coordinated
continuum of
services for
servicemembers
and veterans
with spinal
cord injuries.
----------------------------------------------------------------------------------------------------------------
VA Polytrauma System of VA system of Serious to Social work
Care specialized severe and nurse
facilities that case
provides managers
comprehensive,
individually
tailored
rehabilitation
to
servicemembers
and veterans
with multiple
injuries.
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of DoD and VA program information.
Note: The characteristics listed in this table are general characteristics of each program; individual
circumstances may affect the enrollees served and services provided by specific programs.
a For the purposes of this table, we have categorized the severity of enrollees' injuries according to the
injury categories established by the DoD and VA Wounded, Ill, and Injured Senior Oversight Committee.
Servicemembers with mild wounds, illness, or injury are expected to return to duty in less than 180 days;
those with serious wounds, illness, or injury are unlikely to return to duty in less than 180 days and
possibly may be medically separated from the military; and those who are severely wounded, ill, or injured are
highly unlikely to return to duty and also likely to medically separate from the military. These categories
are not necessarily used by the programs themselves.
b FRCs placed at the headquarters of Special Operations Command's Care Coalition and Navy Safe Harbor
coordinate clinical and nonclinical care for enrollees in these two programs and for other FRCP enrollees.
c OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom.
d An OEF/OIF care manager supervises the case managers and transition patient advocates and may also maintain a
caseload of wounded veterans.
Many recovering servicemembers and veterans are enrolled in more
than one program. For example, in September 2010, approximately 84
percent of FRCP enrollees were also enrolled in a military service
wounded warrior program. However, limitations on information sharing
among the programs has resulted in duplication of services and enrollee
confusion, prompting two military wounded warrior programs to cease
making referrals to the FRCP. Specifically, the FRCP could not share
certain enrollee data maintained on its information system with staff
of non-VA programs because VA had not completed public disclosure
actions necessary to enable the sharing of this information. In January
2011, VA completed the process needed to resolve this issue. In
addition, incompatibility among information systems used by different
case management programs limits data sharing as information about
enrollees cannot be easily transferred among these systems. Although
the ultimate solution to information system incompatibility is beyond
the capacity of the FRCP to resolve, the program has initiated an
effort to improve information exchange.
Finally, FRCs identified several types of logistical problems that
have affected their ability to carry out their responsibilities. These
issues center around (1) provision of equipment such as computers,
printers, landline telephones, and BlackBerrys; (2) technology support
such as equipment maintenance, software upgrades, and systems security;
and (3) private workspace at medical facilities.
Overall, as the first joint care coordination program for DoD and
VA, the FRCP represents a new patient support paradigm for the
departments. Because of its unprecedented nature, the program cannot
refer to preexisting data or policies and procedures to manage the
program, and as a result, FRCP leadership had to develop management
processes as the program was being implemented and has largely relied
on informal processes to oversee and manage key aspects of the program.
However, now that the program has been operating for several years and
continues to grow, it has become apparent that the program would
benefit from more definitive management processes to strengthen program
oversight and decision-making.
As a result of our examination of the FRCP, we recommended that the
Secretary of Veterans Affairs direct the Executive Director of the FRCP
to take actions to establish adequate internal controls regarding FRCs'
enrollment decisions, to complete development of the workload
assessment tool for FRCs' caseloads, and to document procedures to
strengthen FRC staffing and placement decisions. In their comments on
our report, DoD stated that it continues to increase its collaboration
with VA, and VA generally agreed with our conclusions and concurred
with our recommendations to the Secretary.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions you or other Members of the Subcommittee
may have.
Contacts and Acknowledgments
For further information about this testimony, please contact
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this testimony. Individuals who made
key contributions to this testimony include Bonnie Anderson, Assistant
Director; Frederick Caison; Elizabeth Conklin; Deitra Lee; and Lisa
Motley.
Prepared Statement of Karen Guice, M.D., MPP,
Executive Director, Federal Recovery Coordination Program, U.S.
Department of Veterans Affairs
Good morning Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Committee. My name is Karen Guice and I am the Executive
Director of the Federal Recovery Coordination Program (FRCP), a joint
DoD/VA program, administered by VA.
On March 23, 2011, the Government Accountability Office (GAO)
report released its report on the FRCP, along with four recommendations
for program improvement. VA concurred with the recommendations and I
welcome this opportunity to discuss the steps taken since the GAO
report was issued. I would also like to share with you some of the
current and planned approaches to the FRCP's challenges with outreach,
referral, enrollment, communication and staffing in our continuing
collaboration with DoD to provide comprehensive care coordination to
severely wounded, ill or injured servicemembers and veterans.
Background
The Departments of Defense and Veterans Affairs signed two
memoranda of understanding (MOU, August 31, 2007 and October 30, 2007)
establishing FRCP as a joint program and providing operational
parameters. The program was specifically charged with providing
seamless support from the time a servicemember arrived at the initial
Military Treatment Facility (MTF) in the United States through care and
rehabilitation, regardless of whether the goal was to return to
military duty or transition to veteran status.
As required by the MOUs, Federal Recovery Coordinators (FRCs) are
master's prepared nurses and social workers who provide support by
acting as advocates in all clinical and non-clinical aspects of
recovery. FRCs work with the relevant military service and VA programs,
the individual's interdisciplinary clinical team, and all case
managers. Based on a client's goals, with input from all care
providers, the FRC creates a Federal Individualized Recovery Plan
(FIRP). FRCs have delegated authority for oversight and coordination of
all clinical and non-clinical care identified in the FIRP.
Specific FRCP eligibility criteria were approved by the DoD/VA
Senior Oversight Committee (SOC) in October 2007 and included those
servicemembers or veterans who received acute care at MTFs; those
diagnosed with specific injuries or conditions; those considered at
risk for psychosocial complication; and those self or Command-referred
based on perceived ability to benefit from a recovery plan.
FRCs are a unique resource for those with severe and complex
medical and/or social problems. They coordinate benefits and health
care as servicemembers and veterans heal, aligning information and
services to deliver support at the right time and in the right order.
FRCs do not provide direct medical care, issue military orders, or
transport clients to appointments. Instead, they rely on case managers,
both clinical and non-clinical, as well as interdisciplinary health
care team members and servicemembers' units, for those activities. FRCs
anticipate needs and coordinate among service and benefits providers to
ensure smooth transitions for their clients, whether the transition is
between two hospitals or two agencies, in keeping with the intent of
the MOUs signed by the Departments' Secretaries to create a single
joint program for care coordination.
In 2008, the National Defense Authorization Act (NDAA) required the
creation of a recovery coordination program. This program, the Recovery
Coordination Program (RCP), was implemented as a DoD-specific program
for non-clinical case management. Recovery Care Coordinators (RCC) are
assigned to and employed by the Military Services, with the Office of
Wounded Warrior Care and Transition Policy providing program policies.
Although FRCP and RCP provide different services, in an effort to
align responsibilities and roles with appropriate levels of RCP or FRCP
support, the SOC approved three categories of service. Category 1
individuals were those whose recovery was essentially guaranteed and
for whom only medical case management and relevant health care
providers were necessary for full recovery. Category 2 individuals were
those whose recovery had a high probability of requiring at least 180
days and for whom the addition of a non-clinical case manager or RCC
appeared appropriate to assist with service delivery. Category 3
individuals were those with severe and complex medical problems and who
had a high probability of leaving military service. Individuals
identified for this latter category were to be assigned to FRCP. These
service categories and assignment requirements were incorporated into
the DoD Instruction 1300.24 which governs the DoD RCP. Because these
categories are more administrative than operational, accurate category
assignment to FRCP or RCP has been difficult.
GAO Recommendations
The first of four GAO recommendations stated that the FRCP should
establish adequate internal controls to ensure that referred
servicemembers and veterans who need FRC services are enrolled
in the program. VA concurred with this recommendation.
Evaluation of potential FRCP clients is based on an assessment of
the individual's medical and non-medical needs and requirements in
order to recover, rehabilitate, and reintegrate to the maximum extent
possible. A key component in the FRCP evaluation process is the
clinical training and experience of the FRCs and their professional
judgment of whether an individual would benefit from FRCP care
coordination. In general, servicemembers and veterans whose recovery is
likely to require a complex array of specialists, transfers to multiple
facilities, and long periods of rehabilitation are referred to the
FRCP.
Following a referral, FRCs consider a wide range of issues in
determining whether an individual meets enrollment criteria. The first
consideration is whether the referred individual meets with the broad
SOC eligibility criteria. FRCs then conduct a comprehensive record
review to include all relevant and available health and benefit
information. They document the medical diagnoses and conditions. They
conduct a risk assessment; identify anticipated treatment and
rehabilitation needs; determine the individual's access to care and
level of support; identify any issues with medications or substance
abuse; assess the current level of physical and cognitive functioning;
and review financial, family, military, and legal issues. They also
discuss the individual with interdisciplinary clinical team members,
clinical and non-clinical case managers, and others who might provide
insight into the various issues and challenges the servicemembers or
veterans and their families face. Finally, and most importantly, the
FRCs interview the referred individual and family members. Based on all
input, the FRCs determine whether to enroll the referred individual;
FRCP enrollment is entirely voluntary. Individuals who are not enrolled
are directed to alternative resources that are appropriate for their
level of need.
Any program's enrollment criteria should reflect its charge and
mission. For the FRCP, the original eligibility criteria and program's
defined scope were broad, as specified in the MOUs and approved by the
SOC. Following the NDAA 2008 requirement for DoD to create the RCP, and
the SOC's approval of the three service categories, the FRCP's scope
narrowed to reflect only a Category 3 designation. Since then, the FRCP
has been capturing information, based on case experience, to help
refine enrollment criteria. The FRCP will use this information, along
with a service intensity measurement tool (the development of which is
discussed later in this testimony) to define an eligibility protocol
within the program's data management system. In the meantime, the FRCP
requires all FRCs to discuss each enrollment decision with the FRCP
management. The FRCP management makes the final eligibility decision to
ensure enrollment consistency. All enrollment decisions are clearly
documented in the FRCP data management system. This interim solution
was implemented immediately following issuance of the GAO report.
While the FRCP can ensure that all referred severely wounded, ill
or injured servicemembers and veterans who would benefit from care
coordination are enrolled, the FRCP does not have visibility of all who
might be eligible. The FRCP, as currently structured, is a voluntary
referral program and, as such, relies on the identification and
referral of those who might benefit from the FRCP services by others
(case managers, Command, Wounded Warrior Programs, etc.). While the
original MOUs do not specify a specific category of wounded, ill or
injured, the FRCP was relegated to care coordination for severely or
catastrophically wounded, ill or injured once the RCP became
operational. Absent a defined, automatic referral process aligned with
the DoDI 1300.24 or the original intent of the MOUs, the FRCP has
relied on outreach activities and demonstrated outcomes to inform the
referral
process.
One way for the FRCP to increase referrals is through a robust
outreach effort to ensure program awareness. Part of this effort has
been to provide iterative, informational stakeholder briefings. In
2008, the FRCP conducted 17 outreach efforts and presentations to a
variety of audiences, including MTF personnel, DoD and VA program
personnel, and external stakeholders. In 2009 and 2010, the FRCP
conducted almost 100 outreach activities each year. In the first
quarter of calendar year 2011, the FRCP has conducted 34 informational
briefings, on target to exceed previous outreach effort by 25 percent.
The FRCP has created a variety of materials to assist with these
outreach efforts. Program brochures are provided to potential clients
and families, as well as to participants in the FRCP informational
briefings. These brochures are also provided to other groups for
distribution upon request. Along with the brochures, the FRCP developed
posters and banners for use at conferences or presentations. The FRCP
has a 1-800 line for program referrals; approximately 30 percent of
received calls either refer an individual or request more information
about the program. The FRCP is in the process of creating a specific
webpage within the VA's Web site which will contain program and contact
information.
In addition to these outreach efforts, last year the FRCP conducted
a ``look back'' project to identify veterans who might still benefit
from care coordination. This project required access to data for
servicemembers and veterans who: 1) served in the Armed Services since
9/11/2001; 2) were severely wounded, ill or injured; and 3) met the
program's eligibility criteria. No single data source had sufficient
information to determine this population; instead, the FRCP identified
7 different data sets from DoD and VA, which were cleaned and merged to
create a single set of over 40,000 individuals. Within the merged
dataset, certain data elements were selected as a substitutes or
``proxies'' to narrow the list to those more likely to meet the FRCP
program criteria. FRCs then contacted these identified individuals and
identified only 35 who might still require care coordination.
Currently, the FRCP's most common source of referral is from a DoD
or VA clinical case management program or a member of an
interdisciplinary clinical team. Ten percent of all FRCP clients have
been referred by a service wounded warrior program and 1 percent of
referrals have originated from a DoD Recovery Care Coordinator. In
contrast, 38 percent of all FRCP referrals are from clinical case
managers or members of an interdisciplinary clinical team.
The FRCP has been criticized for the inability to provide client
lists to the various case management and military services wounded
warrior programs. All Federal agencies, and their programs, must comply
with the various laws and regulations protecting personally
identifiable and health information. Until recently, the FRCP was not
able to provide other agencies' programs with information about clients
because the FRCP data management system had not gone through a Systems
of Records Notification (SORN) process. With the SORN now in place, the
FRCP has clearly prescribed Federal guidelines for the sharing of
information as well as disclosure rules. The FRCP is currently in the
process of identifying the information required by other programs so
that appropriate data transfer agreements can be developed.
In addition, the FRCP is an active participant in a DoD/VA
information sharing initiative (ISI). The ISI is currently working on
an electronic transfer of information between and among case
management/care coordination programs within the two departments. Six
specific information items have been identified for exchange. These
items are: 1) Names, titles and affiliations of all case/care managers/
coordinators assigned to a servicemember or veteran; 2) Ability to
track benefits applications, benefits processing status and benefits
awards across the DoD and VA; 3) Visibility of all care, recovery or
transition plans (medical and non-medical); 4) Ability to view and
schedule appointments through a shared calendar for servicemembers and
veterans; 5) Role-based visibility of relevant injury or illness
information; and 6) Role-based visibility of a shared servicemember and
veteran problem lists to help identify qualifying benefits.
Requirements for these data transfers are in varying stages of
development, with an anticipated exchange of case manager information
by September 2011.
GAO recommended that FRCP should complete development of a workload
assessment tool. VA concurred with this recommendation.
Care coordination is essential to the effective management of
severely wounded, ill or injured servicemembers and veterans, and
determining the appropriate caseload for each FRC is critical. Since
care coordination is a relatively new concept, particularly as
implemented across and within Federal agencies, no guidelines or
service intensity measurement tools currently exist to accurately
provide a balanced range of cases. The current FRCP caseload target
range of 25-35 cases was based on a review of other programs' caseload
ratios, along with relevant literature, and the awareness that not all
clients will need the same intensity of coordination.
A system intensity measurement tool will measure how much time and
effort a FRC uses to identify ongoing care and required benefit needs
for a client. By collecting uniform information for these activities,
the FRCP can improve resource allocation, determine patterns of need,
target those service areas where the need is critical, and measure
stabilization over time. The FRCP can also use the system intensity
measurement scores to define with improved precision those referred
individuals who would benefit from care coordination, as well as those
individuals whose needs can be met with alternative resources.
Developing such a tool is a labor intensive task that requires
development and testing, along with validity and reliability
assessments. FRCs are currently participating in a process to validate
assumptions, complete a scoring algorithm, and measure inter-rater
reliability prior to full field testing of a new service intensity
measurement scheme. Completing the development of this tool may require
a year or more of intense effort.
GAO recommended that FRCP should better document how hiring decisions
are made. VA concurred with this recommendation.
The FRCP continues to grow in client volume and program referrals.
In fiscal year (FY) 2008, the program received an average of 25
referrals per month. In FY 2009, the average number of referrals
increased to 37 per month, and in FY 2010 the average increased to 50
per month. Of those referred in 2010, 68 percent were enrolled
(Active), 18 percent required minimal assistance (Assist), and 14
percent were redirected to other resources. In FY 2008, the program had
enrolled and cared for 226 servicemembers and veterans. In FY 2010
alone, that number had more than doubled to 598. The current number of
Active clients is 736 with an average FRC caseload between 30-33
clients.
To determine the number of FRC positions required, the FRCP
management considers the number of referrals, the rate of enrollment,
the number of clients made inactive, and a benchmark range of 25-35
cases per FRC. The FRCP has established an equation based on these
elements and incorporated it into the program's operating plan. Upon
completion of the service intensity measurement tool, the FRCP will
modify this equation to reflect the average intensity points allowed
per FRC instead of the current arbitrary 25-35 benchmark case range.
The FRCP will update staffing processes and plans in the annual
business operation planning document.
Currently, 22 FRCs are working at six military treatment
facilities, four VA medical centers, and two Wounded Warrior Program
headquarters. FRCs are supported by a VA Central Office staff that
includes an Executive Director, two Deputies (one for Benefits and one
for Health), an Executive Assistant, an Administrative Officer, and two
Staff Assistants. In the past, the FRCP has received personnel support
at VA Central Office from the U.S. Public Health Service and DoD. While
the Navy has designated an individual for detail to FRCP, in accordance
with the MOU, no other military support is currently forthcoming.
GAO's final recommendation was that the FRCP should develop and
document a rationale for Federal Recovery Coordinator (FRC)
placement. VA concurred with this recommendation.
The FRCP will develop a FRC placement strategy based upon a
systematic analysis of data over the next 6 months. The FRCP's initial
placement was guided and directed by the MOU, which required that FRCs
be placed at MTFs where significant numbers of wounded, ill or injured
servicemembers were located. As the program has grown, and given the
current requirement for a single FRC to remain assigned to a client for
optimal care coordination and consistency, the FRCP has considered
alternative locations. FRC placement is guided by four factors:
replacement for FRCs who leave the program, supplementation of existing
FRCs based on documented need, creation of a national ``FRCP network''
to optimize coordination, and specific requests for FRCs in order to
better serve the wounded, ill and injured population of servicemembers
and veterans. The actual placement of FRCs is based on a case-by-case
negotiation for space and support.
Conclusion
Many believe that the FRCP is a redundant program; others suggest
that because the FRCP is administered by VA and is not in the military
services' chain of command that the FRCP should only provide support
for veterans. There are numerous programs that that support
servicemembers and veterans with recovery. Each of the military
services has programs that provide lifetime support servicemembers from
the time of injury or diagnosis through recovery. For example, the
Marines provide a RCC for every wounded, ill or injured Marine with
additional support, command, and control provided through the Wounded
Warrior Regiment. The Army provides the Warrior Care and Transition
Program for case management and command and control, along with the
Army Wounded Warrior (AW2) Program for the most seriously wounded ill
or injured soldiers and veterans. The Air Force Warrior and Survivor
Care Program and Air Force RCCs care for wounded, ill and injured
Airmen. The Navy has the Safe Harbor Program and the Special Operations
Command has the Care Coalition.
Each MTF provides clinical case managers for both inpatient and
outpatient case management; TRICARE also provides case managers. The
Veterans Health Administration (VHA) has the Operation Enduring
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)
clinical case managers at each VA medical center, who assist OEF/OIF/
OND servicemembers and veterans navigate the VA's health care system.
In addition, there are VHA Liaisons at many MTFs, along with Polytrauma
Nurse Liaisons, who coordinate the transfer of servicemembers to VA's
health services and programs.
VA also provides home-based primary care; blind, Traumatic Brain
Injury (TBI), and spinal cord rehabilitation programs; the homeless
program, caregiver support personnel, and more. Each of these programs
provides case management, many of them for the lifetime of the veteran.
VBA has vocational rehabilitation and the benefits assistance program
with additional case managers providing support to the servicemember
and veteran. In addition, there are many other programs, such as the
Defense Center of Excellence In-Transition Program, the National Guard
Transition Assistance Advisor, Defense and Veterans Brain Injury
Center's Recovery Coordinators, who also provide case management
activities for wounded, ill or injured servicemembers.
Many wounded, ill and injured servicemembers, veterans and their
families are confused by the number and types of case managers and
baffled by benefit eligibility criteria as they move through the DoD's
and VA's complex systems of care on the road to recovery. The FRCP was
envisioned to be the single point of contact for these individuals
through care and recovery; a single point of contact that would help
them understand the complexities of the medical care provided and the
array of benefits and services available to assist in recovery.
Currently, the FRCP is the only joint DoD/VA program that provides
clinical and non-clinical care coordination for wounded, ill or injured
servicemembers, veterans and their families with severe and complex
medical and social problems. The FRCP provides alignment of services,
coordination of benefits, and resources across DoD, VA and the private
sector by managing transitions and providing system navigation for
clients.
The program works best when FRCs are included early in the
servicemember's recovery and prior to the first transition, whether
that transition is from inpatient to outpatient or from one facility to
another. One FRC will stay with that individual throughout all
subsequent transitions, coordinating benefits and services as needed.
This consistency of coordination is important for individuals with
severe and complex conditions who require multiple DoD, VA and private
health providers and services. FRCs remain in contact with their
clients as long as they are needed, whether for a lifetime or a few
weeks. FRCs involvement is voluntary and, when used as envisioned,
collaborative. However, FRCP cannot carry out this mission without
active support from the DoD, including all military services, the VA,
and Congress.
In closing, program evaluation, whether by Congress or by an
investigative body such as GAO, is a vital part of program growth and
maturation. The FRCP is grateful to the GAO for their comprehensive
review and to the Subcommittee Members for this opportunity to discuss
continued challenges.
Thank you and I look forward to your questions.
Prepared Statement of Robert S. Carrington, Director,
Recovery Care Coordination, Office of Wounded Warrior Care and
Transition Policy, U.S. Department to Defense
Madame Chairwoman and Members of the Subcommittee:
Thank you for the opportunity to discuss the Department of
Defense's (DoD) role in the Federal Recovery Coordination Program
(FRCP). While the FRCP was jointly developed by DoD and Department of
Veterans Affairs (VA) leaders on the Senior Oversight Committee (SOC),
the program itself is implemented by VA.
Overview of DoD Recovery Coordination Program
The DoD Recovery Coordination Program (RCP) was established by
Section 1611 of the FY 2008 National Defense Authorization Act. This
mandate called for a comprehensive policy on the care and management of
covered servicemembers, including the development of comprehensive
recovery plans, and the assignment of a Recovery Care Coordinator for
each recovering servicemember. In December 2009, a Department of
Defense Instruction (DoDI) 1300.24) set policy standardizing non-
medical care provided to wounded, ill and injured servicemembers across
the military departments. The roles and responsibilities captured in
the DoDI are as
follows:
Recovery Care Coordinator: The Recovery Care Coordinator
(RCC) supports eligible servicemembers by ensuring their non-medical
needs are met along the road to recovery.
Comprehensive Recovery Plan: The RCC has primary
responsibility for making sure the Recovery Plan is complete, including
establishing actions and points of contact to meet the servicemember's
and family's goals. The RCC works with the Commander to oversee and
coordinate services and resources identified in the Comprehensive
Recovery Plan (CRP).
Recovery Team: The Recovery Team includes the recovering
servicemember's Commander, the RCC and, when appropriate, the Federal
Recovery Coordinator (FRC), for catastrophically wounded, ill or
injured servicemembers, Medical Care Case Manager and Non-Medical Care
Manager. The Recovery Team jointly develops the CRP, evaluating its
effectiveness and adjusting it as transitions occur.
Reserve/Guard: The policy establishes the guidelines that
ensure qualified Reserve Component recovering servicemembers receive
the support of an RCC.
There are currently 146 RCCs in 67 locations placed within the
Army, Navy, Marines, Air Force, United States Special Operations
Command (USSOCOM) and Army Reserves. Care Coordinators are hired and
jointly trained by DoD and the Services' Wounded Warrior Programs. Once
placed, they are assigned and supervised by Wounded Warrior Programs
but have reach back support as needed for resources within the Office
of Wounded Warrior Care and Transition Policy. DoD RCCs work closely
with VA FRCs as members of a servicemember's recovery team.
In the DoDI we have codified that severely injured and ill who are
highly unlikely to return to duty and will most likely be medically
separated from the military (Category 3) will also be assigned a FRC.
The DoDI 1300.24 establishes clear rules of engagement for RCCs and
FRCs. The RCC's main focus is on servicemembers who will be classified
as Category II. A Category II servicemember has a serious injury/
illness and is unlikely to return to duty within a time specified by
his or her Military department and may be medically separated. The
FRC's main focus is on the servicemembers who are classified as
Category III. A Category III servicemember has a severe or catastrophic
injury/illness and is unlikely to return to duty and is likely to be
medically separated.
While defined in the DoDI, Category 1 and 2 and 3 are all
administrative in nature and have been difficult to operationalize. The
intent of the controlling DoDI is to ensure that wounded, ill, and
injured servicemembers receive the right level of non-medical care and
coordination. DoD is working with the FRCP to make sure that
servicemembers who need the level of clinical and non-clinical care
coordination provided by a FRC are appropriately referred.
Government Accountability Office (GAO) Report on Federal Recovery
Coordination Program
Although the FRCP is exclusively run and managed by VA, there is a
presumptive ``hand-off'' from DoD Recovery Care Coordinators, and DoD
medical case managers to the Federal Recovery Care Coordinators at the
point that it is clear that the catastrophically wounded, ill, or
injured servicemember will not return back to duty. This determination
is highly complex and individualized based on a variety of factors
including the servicemember's condition, and their desire to stay on
active duty.
The majority the findings of the March 2011 GAO Report ``Federal
Recovery Coordination Program Continues to Expand, but Faces
Significant Challenges,'' pertain to implementation and oversight of
the FRCP. There are, however, two areas of the report that directly
involve DoD:
Duplication of case management efforts between VA and DoD
Lack of access to equipment at installations
Duplication of case management efforts between VA and DoD
The report outlines the confusion and inefficiency that arises as a
result of a servicemember who may have multiple case managers. The GAO
report shows a matrix with the various DoD and VA care/case management
programs in place. As many as 84 percent of servicemembers in the FRCP
are also enrolled in a Military Service Wounded Warrior Program. While
the programs vary in the populations they serve and services they
provide, there is significant overlap in functions.
The GAO outlined one instance where a recovering servicemember was
receiving support and guidance from both a DoD Recovery Care
Coordinator and a VA Federal Recovery Coordinator. The two coordinators
were effectively providing opposite advice and the servicemember was in
receipt of conflicting recovery plans. The servicemember had multiple
amputations and was advised by his FRC to separate from the military in
order to receive needed Services from the VA, whereas his RCC set a
goal of remaining on active duty.
The SOC subsequently directed RCP and FRCP leadership to establish
a DoD-VA Recovery Care Coordination Executive Committee to identify
ways to better coordinate the efforts of FRCs and RCCs and resolve
issues of duplicative or overlapping case management. The Committee
conducted its first meeting in March and its final 2-day meeting
earlier this week. The results of the Committee's efforts will be
briefed to the SOC at its next meeting.
In March 2011, DoD also conducted an intense 2\1/2\ day Wounded
Warrior Care Coordination Summit that included focused working groups
attended by subject matter experts who discussed and recommended
enhancements to various strategic wounded warrior issues requiring
attention. One working group focused entirely on collaboration between
VA and DoD care coordination programs and best practices within
recovery care coordination and wounded warrior family resiliency.
Actionable recommendations are currently being reviewed, have been
presented to the Overarching Integrated Product Team (OIPT) and will
continue to be worked until the recommendations and policies are
implemented.
Lack of access to equipment at installations
FRCs reported to the GAO that ``logistical problems'' impacted
their ability to conduct day-to-day work. Specific areas causing this
include: a) provision of equipment, b) technology support and c)
private work space. There are existing Memoranda of Agreement between
the FRCP and the DoD and VA facilities where FRCs work, however
compliance with these MOAs remains a challenge.
DoD's Office of Wounded Warrior Care and Transition Policy (WWCTP)
is currently evaluating the resources required at DoD facilities for
both Recovery Care Coordinators and Federal Recovery Coordinators.
WWCTP will work with the Services and the VA to ensure that daily
duties are not interrupted by equipment, technology or space
constraints.
Conclusion
DoD is committed to working closely with the VA Federal Recovery
Coordination Program leadership to ensure a collaborative relationship
exists between the DoD RCP and the VAFRCP. The Military Department
Wounded Warrior Programs will also continue to work closely with FRCs
in support of servicemembers and their families.
Madam Chairwoman, this concludes my statement. On behalf of the men
and women in the military today and their families, I thank you and the
Members of this Subcommittee for your steadfast support.
Prepared Statement of James R. Lorraine, Executive Director,
Central Savannah River Area--Wounded Warrior Care Project, Augusta, GA
Chairman Ann Marie Buerkle, Representative Michaud, and
distinguished Members of the Committee: thank you for the opportunity
to speak with you today about the Federal Recovery Coordination
Program. First of all, I'd like to thank this Committee for its
continuing efforts to support servicemembers, veterans, and their
families as they navigate through the complex web of Department of
Defense, Department of Veterans Affairs, and civilian programs. I've
been a member of the military community my entire life; as a Reservist,
Active Duty Air Force, Military Spouse, Retiree, Government Civilian,
and Veteran. In my previous position as the founding Director of the
United States Special Operations Command Care Coalition; an
organization which advocates for over 4,000 wounded, ill, or injured
special operations forces and has been recognized as the gold standard
of non-clinical care management. Recognizing a gap in my Special
Operations advocacy capabilities, I incorporated a Federal Recovery
Coordinator as a team member in providing input to the recovery care
plans for our severely and very severely wounded, ill, or injured
servicemembers. This one Federal Recovery Coordinator dramatically
improved how Special Operations provides transitional care coordination
and made my staff more efficient in support of our special operations
warriors and families throughout the Nation. I've found that when
supporting our servicemembers, veterans, and their families there is
always opportunity for improvement.
It's essential that our military and veterans have strong
advocates, both government and non-government, working together at the
national, regional, and community levels to improve the recovery,
rehabilitation, and reintegration of our warriors and families.
However, one program by itself is not enough when it comes to
supporting our Nation's most valuable resource--the men and women of
the Armed Forces, our veterans, and their families. I recently left
government service to assume duties as the Executive Director of the
Central Savannah River Area--Wounded Warrior Care Project, where my
current position is to integrate services by developing a strong
community based organization that maximizes the potential of government
and non-government programs in Augusta and throughout our region. The
Federal Recovery Coordination Program is one of those resources.
From my experience, advocates or care coordinators require three
attributes in order to be successful. The first attribute is the
ability to anticipate need. This may sound simple, but staying ahead of
a problem saves a lot of heartache, money, and time. Much like chess
master, thinking five to ten moves ahead, this assumes effectiveness
and competence at various levels of the system. The second attribute is
the authority to act. A case manager or advocate who anticipates needs
and develops flawless transition plans, but doesn't have the authority
to act is powerless to ensure success. In this complex environment of
wounded warrior recovery, someone who can not act is an obstacle. The
last attribute is the access to work as a team member. This is
recognizing that it takes more than one person to reach the goal. Team
work is probably the most complex of the three attributes, because it
requires others to be inclusive, sharing of information, trust, and
requires a great deal of time to coordinate and synchronize efforts.
Federal Recovery Coordinators are a critical component to the
successful reintegration of over a thousand wounded, ill, or injured
and their families, but as I said ``there is always opportunity for
improvement''.
By design a Federal Recovery Coordinator has the education and
credentials to anticipate need. Their level of professionalism, skill,
and experience enables the coordinator to function at a high level of
competence in supporting our warriors. They are the most clinically
qualified of the warrior transition team. However, not everyone has the
same clinical expertise and access to perform as a Federal Recovery
Coordinator. We feel the development of a Federal Recovery Coordinator
certification program is necessary to prepare these Veterans Affairs
care coordinators to engage a broad spectrum of resources available in
areas not only of health care, but with a focus on behavior health,
family support, and benefits availability.
Innately, the FRC has the authority to act within the Veterans
Affairs Health Care system and interface with Veterans' Benefits
Administration representatives. By reporting to the Veterans Affairs
Central Office the Federal Recovery Coordinator can influence across
the Nation and regionally. This ability is unique and should be
capitalized on by the Department of Defense Service Wounded Warrior
programs and strengthened by the Veterans Benefits Administration. The
Federal Recovery Coordinator must have the authority to act at the
strategic level, to ensure case management is being accomplished,
services are being provided, and that Veterans Affairs resources are
being maximized, in concert with other government and non-government
organizations.
The greatest challenge for the Federal Recovery Coordination
Program is their access to work as a team member. As I mentioned
earlier, team work requires inclusiveness. If the Coordinators do not
have timely access to the warriors and families in need they can't be
effective. As the saying goes ``You only know what you know.''
Involvement in a case must be timely in order to shape an outcome, vice
manage the consequences of bad decisions. We must work symbiotically to
synchronize our efforts, operating transparently, and maximizing the
capabilities of the Departments of Defense, Veterans Affairs, Labor,
and Health and Human Services, as well as collaboration with non-
government organizations at the national, regional, and local levels.
Additionally, the Federal Recovery Coordinators must function in a
coordination role, working by, through, and with Service Wounded
Warrior Programs while also leveraging local Veterans Affairs case
managers and benefits counselors. Relationships are critical and the
Federal Recovery Coordinator must develop trusting interchange with
those individuals and organizations with the mission to assist the
servicemember, veteran, and their family.
Lastly, the scope of the Federal Recovery Coordination Program
should be expanded to assist those in the greatest need for a
transitional care coordinator. We should not only support the most
severely wounded, ill, or injured, but must include those less severe
whose family dynamics, behavioral health issues, or benefit anomalies
inhibit their smooth transition to civilian life. The current practice
of providing ``an assist'', which is short term without fully involved
care coordination, has been successful. Additionally, those
transitioning veterans at the greatest risk for homelessness should
have a Federal Recovery Coordinator shepherd the veteran to success. By
operating at a strategic level Federal Recovery Coordinators can affect
the outcome of far more veterans both regionally and locally.
In conclusion, we have three recommendations to improve the Federal
Recovery Coordination program.
1. Maintain the high credential standards for the Federal Recovery
Coordinator, but augment with a nationally recognized certification for
Federal system care coordination in order to strengthen their ability
to anticipate needs.
2. Ensure the Federal Recovery Coordinators have the authority to
act on needs they've identified, both on a national and local level.
3. Make certain the Federal Recovery Coordinator has access to
work as a team member. Incorporate Federal Recovery Coordinators early
in the recovery process as strategic partners who can ensure the
Veterans Affairs resources are maximized to a larger population of
transitioning servicemembers, veterans, and their families in need of
someone to shepherd them through this complex system.
There is currently a very positive feeling in this country towards
the service and sacrifice of our military, veterans, their families,
and a desire to support them. One way to help is to utilize existing
programs, especially at the local level. The Central Savannah River
Area--Wounded Warrior Care Project stands as the model for many
communities throughout the Nation who are at the front line of helping
our veterans come all the way home from combat and fully reintegrate
into our community. It's also important to educate the military and
their families about their transition, but it's frequently too late
after transition has occurred and life's daily pace takes over.
Thank you for providing us the opportunity to present before the
Veterans' Affairs Subcommittee on Health.
Prepared Statement of Mary Ramos, Ph.D., RN,
Federal Recovery Coordinator, San Antonio, TX, Military Medical Center,
U.S. Department of Veterans Affairs
Good morning Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Committee. My name is Mary Ramos, and I work at the San
Antonio Military Medical Center as a Federal Recovery Coordinator
(FRC).
When asked what I do for a living, the simple answer is that I
coordinate long-and short-term care for the most seriously wounded,
ill, and injured for the Department of Defense (DoD) and the Department
of Veterans Affairs (VA). I say that I help clients get everything they
need from DoD, VA, and the community. People ask if that job is very
difficult. I have to say that it is certainly a challenge, but also a
gift. It is an honor working with servicemembers and with veterans and
their families; every day is a learning experience in how people,
health care, and systems interface to provide care and benefits to
those in need.
I will begin my testimony by providing you with a general picture of
who a FRC is, our roles and responsibilities.
My position as a FRC is embedded in a Military Treatment Facility
(MTF), San Antonio Military Medical Center (SAMMC). We at SAMMC work
hand-in-hand with military health care providers, VA and civilian
providers, case managers, care coordinators, and military command as
well as countless others whose roles touch the wounded, ill, and
injured clients and their families. Our roles as FRCs are unique within
the military and VA health care and benefits systems, and each day
brings discoveries about the respective niches we fill in providing
care and caring for our clients.
The FRC role is one of overarching coordination. In operational
terms, that means that while others have a defined ``lane,'' FRCs
coordinate across those ``lanes'' for our clients. The FRC communicates
with key members of the provider team within a clinical setting and, in
partnership, assesses whether there are interventions or information
that might assist those providers in optimizing clinical and social
outcomes. For instance, health providers treat the various medical
conditions while the clinic staffs facilitate appointments. The FRC
will identify client or family issues with transportation, motivation,
adherence, or information. If there are such issues, the FRC will
validate those impressions with the treatment team and encourage
additional personnel participation to provide what is needed,
facilitating clinical and nonclinical care. This function is critical
when a client is being seen in multiple clinical settings within a
single facility and even more so when he or she is being seen
concurrently in multiple facilities.
On any given day, an active client might be admitted to a hospital,
transferred between facilities, undergo a procedure, or be seen in one
of the outpatient clinics. Tracking those events is critical to
anticipating emerging needs for the clients and families as well as
indicating to whom we should be communicating that day--for example,
the client's inpatient case manager, Warrior in Transition Case
Manager, Recovery Care Coordinator (RCC), VA Liaison for Health care,
VA Case Manager, or provider may be providing care that the FRC can
support or facilitate. The client's changing status may introduce
questions or identify new immediate needs; an unanticipated change may
introduce some instability in an already precarious client's coping
strategy. The FRC, then, is constantly reassessing the status of each
client, balancing past, emerging, and anticipated needs within the
system of care and formulating flexible care coordination plans within
the caregiver matrix. That reassessment may also result in a client
being evaluated for a decrease in acuity within the program.
The Federal Recovery Coordination Program (FRCP) is most beneficial
during periods of recovery and rehabilitation when the FRC can provide
stability and support during transitions. Once a client has settled
into veteran status, is receiving benefits and has decided to return to
school or work, the need for FRCP involvement is often reduced. These
clients may transition to ``inactive'' status with FRCP. Inactive
status does not mean that FRCP support is withdrawn entirely. Inactive
clients can continue to call the FRC at any time for any reason, but
regular contact and the associated Federal Individualized Recovery Plan
(FIRP) work will be discontinued. Sometimes clients are made inactive
if the client is unresponsive to the FRC's outreach for at least 3
months. After that time, the FRC will send a letter to the client
stating that they may become inactive or if they contact the FRC, they
will remain active. Under these particular circumstances, the FRC will
contact any known case manager to ensure the client is receiving
appropriate services.
Referrals come to the FRCs at SAMMC in several ways. Most of my
referrals come directly to me from VA or MTF case managers, RCCs,
military personnel, health care providers, or from current patients
referring their friends. I will also get referrals from VA Central
Office. All referrals are always accepted and reviewed, since one of
the goals of the FRCP is to provide consultative services to the
facility and to respond positively to all questions.
When an FRC receives a referral, the first level of review for
evaluating possible clients is to collect data from the referral source
concerning the client's medical condition, injuries, and social and
family data as well as the referral source's impression of the major
issues that may be facing the possible client in the next weeks.
If there is a single issue or a simple question, the
client may be assessed briefly and entered into the system as an
``assist.'' If ``assists'' prove to grow in complexity or if the
client's condition starts to indicate that he or she will benefit from
the full FRCP, the ``assist'' client can be moved into active status
after the FRC discusses the client with supervisory staff.
Comprehensive clinical review is usually accomplished
with the client placed in ``evaluate'' status.
If the clinical condition or other factors do not
indicate that the FRCP would be of benefit to the client or family, or
if optimal services are being provided, the FRC may, after discussion
with the team and with supervisory staff, ``redirect'' the client back
to the team, offering continuing support as needed but without active
involvement of the FRC.
If the clinical condition of the client indicates a
possible long-term need for the FRCP, the referred individual's health
care records may be reviewed to validate how the FRCP might benefit the
individual and family. Additionally, the individual and/or family are
interviewed, the program is explained, and the individual and family
are given the choice of whether to enroll in the program. If the
individual does not want the program, the choice is left open for the
indeterminate future. If they decide to enroll, the individual is
placed in ``evaluate'' status. Further assessment follows until a
discussion with supervisors may result in the client being placed in
``active'' status.
FRCs at SAMMC introduce clients to the FRCP very early in the
initial hospitalization. While each client has a full complement of
caregivers and case managers in this phase of high acuity, there are
nonclinical details that can be introduced that will facilitate care
and quality of life later in the recovery process. While the client is
in the inpatient setting, the FRC provides additional emotional support
to the client and family and, in partnership, facilitates whatever
processes the case manager and clinical team suggest. The FRC can
monitor processes like application for Servicemembers Group Life
Insurance Traumatic Injury Protection Program (TSGLI) and Social
Security Disability Insurance (SSDI). The FRC can investigate available
resources and help arrange after-school child care to enable the spouse
to be with the injured servicemember.
In providing such assistance, FRCs establish themselves as willing
team members who support not only the client, but the entire care team.
Willingness to serve as a team member is critical to the FRC being
successful in this unique role. Another function of the FRC is to
provide information about resources and benefits that are or will be
available to the client and family. Thus, emotional support,
instrumental assistance and information are the products of the FRCP in
the acute treatment phase.
The most important element the FRC contributes at this early
treatment phase is the concept of seamless long-term clinical and non-
clinical support. The FRC will be the consistent person in their
journey from the most acute care through, and perhaps beyond, community
reintegration. It is true that when the client is in intensive care, he
or she is not thinking about whether or not they will want to leave the
service or whether they will seek funding to attend college. But, the
FRC can assure the client that when they are ready for those decisions,
the FRC will still be there, carrying information about what the
immediate past has been for this family and supporting the decisions
within the close professional relationships that have grown over time.
Because of early support during the most acute phases of care, plus
a long record of supporting the family through various crises, the FRC
builds the closest of professional relationships. Later care is
mediated through that relationship. The trust relationship with the
client and family is the foundation for continued support through the
stresses and decisions that come with the Integrated Disability
Evaluation System (IDES) process and transitions into community life
and new health care delivery systems. With constant interaction from
early in the recovery trajectory through reintegration into the
community, the FRC learns how each client and family member copes and
reacts to the stress of injury, treatment, and change. That knowledge
shapes FRC responses to each client for the provision of individualized
care.
Extensive professional education and experience enable each FRC to
make rapid, continuous assessments and formulate action plans
efficiently both independently and within multiple teams. Each FRC
holds at least a Master's Degree in a health care field with basic
education as either a Nurse or a Social Worker. Many have practiced in
multiple clinical settings. FRCs bring that clinical experience to the
FRC cohort and to the practice setting. The variety of events,
outcomes, roles and personalities in military, VA, and civilian health
care settings demand an unusual level of professional adaptability in
FRC practice. Through the course of each client's health care and
recovery, the FRC role flexes to provide whatever is needed at any
time. Assessment data are constantly processed and actions formulated
to ``fill in the blanks.''
Despite our expertise and experiences, it is expected that FRCs
will be in a constant learning mode. The spheres of knowledge necessary
for the position include physical and behavioral health domains, but
that knowledge is utilized in a context including organizational
psychology, systems theory and transitions, military command systems,
military pay systems, military health care, military justice systems,
military health care finance, evidence-based practice and research, VA
systems of health care, VA benefits systems, community-based care and
health care reimbursement, Federal, State and local tax structures,
civil and criminal legal systems, real estate law, guardianships and
powers of attorney, and risk communication. Additionally, the FRC must
understand how to recognize their own personal knowledge deficits and
to seek resources to apply to emerging situations. Recognizing what one
does not know as a FRC is as important as knowing and teaching what is
known.
FRCs practice with many others who coordinate and provide care for
patients. The FRC role in coordinating care, however, is unique in
several aspects. While the FRC may not possess comprehensive knowledge
concerning any one aspect of a client's life, he or she can see that
aspect in the context of the client's entire life. The FRC contributes
by assimilating what is meaningful to the client's care and by
formulating an overarching care coordination plan. Service-based
personnel may understand the culture of the service much more deeply
than the FRC. The FRC will defer to the Service-based representative in
decisions concerning Service-related issues. However, with broader
clinical knowledge and the ability to incorporate key elements of
service-related information, the FRC can build a new care context for
the client. Some explain this as ``breadth versus depth.''
The care coordination role sometimes colors the character of the
relationship between the FRC and the client and family. The FRC
identifies processes and actions that must take place in the course of
treatment and care management, and then ensures that those tasks are
completed. The quasi-oversight function means that the FRC validates
processes with the team members and clients and observes and assists,
as needed. The FRC listens attentively to the client's perspective and
impressions of care, providing encouragement and assurance that
processes will be completed. Listening and responding can accentuate
the trust relationship and result in a more therapeutic-type
relationship than other roles. Maintaining professional boundaries and
confidentiality is critical to sustaining an appropriate relationship,
especially in light of clients' and families' tendencies to disclose
intimate details of their lives.
Relationships with other professionals within the military
treatment facility are defined by the documents that set the FRCP in
place. The FRCs are provided office space and resources to support
their work, and they are given access to clinical teams, patient
documents, and information systems. At SAMMC, the FRCs are co-located
with a large group of Warrior in Transition Unit (WTU) case managers
and the WTU clinical staff. FRCs participate in clinical activities and
assist providers in various care processes, establishing their roles as
team members. The FRCs meet and greet incoming Commanders of WTU, the
MTF Commander, and other key personnel. Interdisciplinary meetings are
very productive for the FRCs, including those at the Center for the
Intrepid (amputee care) and the outpatient Burn Unit meetings. Each
professional encounter serves as an outreach opportunity and to enhance
an appreciation of what the FRCP can offer to teams and clients.
FRCs have open door policies, and while some clients will make
appointments, some just call or e-mail to ask if they can drop in, or
they just come to talk. When a client presents, the FRC checks the
extant FIRP, goes over all open goals, or formulates a new plan if
necessary. If a client is hospitalized, the FRC will visit several
times a week and will interact with the inpatient case manager to see
if the FRC can assist with any functions. FRCs have access to client's
outpatient appointment schedules and can meet them in the clinics as
desired by the clients and families. FRCs receive a copy of patients
scheduled in the Center for the Intrepid for outpatient
interdisciplinary clinic. It is beneficial to meet with the client's
care team and listen to their impressions of the client's progress, any
barriers to ongoing care, and what is planned in the clinic visit. By
being quietly present, the FRC can be available to answer questions. By
observing the clinical team caring for the client, the FRC can gain
insight as to how the client is interfacing with the team and whether
any FRC coordination would enhance care. Every interaction with the
clinical and nonclinical staff serves as outreach. Every success
ensures future referrals to the FRCP.
I would like to give you some specific examples of what I, as an
FRC, do in a typical work day.
I will review my client list early in the work day using our
program's data management system to review tasks. Much of the early
activity of the day involves planning and prioritizing, processing
incoming e-mails and calls. Of course, the day will never follow the
plan, and priorities evolve during the day, but reviewing issues is
always beneficial. As an example of our task management, if a new
veteran contacts me with a concern that his first benefits check is
lost in the system, as a FRC, I can check on the processing of his
claim and either resolve an issue or reassure the client that the
system is working. Task reminders also cue the FRC to review a client's
record to check and see if benefits have been received.
I reviewed the Veterans Health Administration (VHA) record for a
client diagnosed with schizophrenia, who recently moved to another
city. The client has pending examinations to support the disability
rating. VHA's records indicated active communication between the case
manager in the originating city and the receiving case manager. To
ensure a seamless transition of the client's case, I e-mailed the new
case manager and Transition Patient Advocate, introducing myself and my
role and offering support. I also spoke with the client to inquire if
there were any other issues I could help address.
I received an e-mail from a Polytrauma Rehabilitation Center (PRC)
case manager stating that a head injury patient, who was expected to be
transferred back to his home VA facility, will be remaining at the PRC.
I e-mailed the Veterans Benefits Administration (VBA) representative
about the planned home modifications to determine if they would
continue on schedule or, given the circumstance, would be delayed or
cancelled. I then spoke to the VBA representative and discussed how
best to support the family in caring for the client at home following
discharge from the PRC. The family has decided to check on new
construction rather than modifying the current home. I exchanged e-
mails with the spouse of this client to check on the family's well-
being.
I received an e-mail from a client's spouse, who is waiting for
home modifications. Temperatures are rising with the seasonal change,
and the client has very little tolerance for heat due to burn injuries.
I talked to the local VBA representative, who stated that logistics
were slowing down the process but that he would speak to the client to
plan for starting the project. I then directed the spouse to check the
Service-Disabled Veterans Insurance Web site, and followed up as to
whether the county property tax exemption paperwork had been filed.
I received a phone call from a client's mother. The client is
experiencing disturbing medication side effects. She was very upset
about several other issues as well, including some recent legal issues
and a critical illness in another family member. I provided supportive
listening and encouragement. I e-mailed the VHA case manager and asked
her opinion about whether the primary care provider might consider
seeing the client for a possible medication change. The VHA case
manager arranged the appointment.
I received a phone call from the mother of a veteran who is worried
that the veteran is not receiving optimal care in a transitional
traumatic brain injury (TBI) facility. The mother states that she is
afraid that after 3 years of caring for the veteran, her health is
suffering, and she has no health insurance or income. She discussed her
fear that if the veteran is enrolled in an Independent Living Program
and stays in a transitional TBI treatment facility, that she will have
to sign over the veteran's VA benefits and she will have no income and
no place to live. I called the head of the TBI program to discuss
whether the veteran meets criteria for placement and how the current
family situation might have an impact on program expectations. I also
called the Veteran Outreach Specialist at a local Vet Center to see if
she can assist in finding counseling resources for the mother of the
veteran.
I received a phone call from a veteran receiving inpatient
treatment at a VA Medical Center (VAMC). The veteran called me to
clarify whether a Power of Attorney was needed now or whether it could
wait until after being discharged from the VAMC. The veteran's spouse
is working on financial issues and is worried about money. I e-mailed
the VBA Regional Office to check on the client's VA claim adjudication
since the family is in financial distress and needs an income. Regional
Office personnel confirmed that the client's claim is proceeding. The
veteran also expressed anxiety about leaving the current treatment
program. I assured the veteran that I have been planning clinical
outpatient follow up so that there will be no interruption in
treatment. The veteran expressed appreciation for all of the help, and
offered to help other veterans facing similar issues.
I met with a case manager to discuss two mutual cases. One of the
cases involved an active duty servicemember with a head injury.
Rehabilitation progress at this time is slow, and we discussed whether
there is an alternative placement or if the current placement is the
best. The spouse and mother of the servicemember are discussing the
best approach and are anxious about different issues. The mother would
like the patient in an acute rehabilitation setting. The spouse is
worried about the children, legal, and financial complications. We
discussed the best physical location for the servicemember, given the
demands of multiple compensation and pension examinations in support of
the Medical Board process. We also discussed the family's applications
for an auto grant and special adaptive housing, and misinformation that
had been given to the spouse during the filing process. By the end of
the meeting, we had developed a single message for all family members
in order to decrease family anxiety.
A Navy Safe Harbor (NSH) case manager stopped by my office to
discuss a case that was troubling her. We discussed her concerns and
the scope of the issues with the individual. I then reviewed DoD and
VHA treatment records and discussed the case with the FRC located
within NSH. My review of the records indicated that the individual has
significant physical and behavioral health issues, and that the current
care for these conditions is fragmented. I spoke with the individual
and discussed FRCP structure and function. The individual expressed an
interest in the support that the FRCP can provide, and agreed that he
would work with me to develop a FIRP. I placed the individual in
evaluation status and again discussed with NSH case manager and with
the FRC at NSH. Navy personnel support the individual working with me
as his FRC in partnership with NSH.
I received an email from a veteran who had been told that he had
lost his TRICARE coverage. As for many, the interface between Federal
programs became quite frustrating. An example is this complex
relationships between Social Security Disability Income (SSDI),
Medicare, and TRICARE. This wounded servicemember applied for SSDI soon
after injury and started receiving SSDI within the first 6 months
following his severe injury. After 2 years of being on SSDI, the
veteran became Medicare eligible. At that time, Medicare B premiums
were deducted from his SSDI (Medicare A is without cost). The SSDI
benefit continued when the (then) veteran returned to work. SSDI
payment was suspended after 9 months of the veteran's earning more than
$1000 a month. At that time, the Medicare Program billed the Veteran
for Medicare premiums. He did not understand the bills and did not pay
them. Medicare is suspended. Consequently, TRICARE eligibility ceased.
My role was to explain this complicated situation, encourage him to
report to the local Social Security office, and assure him that he
would get any health care he needed during any transition periods.
I met with another client, who was recently discharged from the
hospital. The client and spouse are interested in purchasing a home;
however, they have a poor credit rating and have only saved part of
their initial TSGLI to use as a down payment. We reviewed all open
goals in the FIRP with the client, discussed financial counseling
resources, the financial commitment of owning a home, and I provided
multiple brochures and contact information. We also discussed the
advantages of financial planning and strategies to raise their credit
rating.
Conclusion
The examples I have provided hopefully demonstrate for you the kind
of flexibility each FRC must have in providing optimal care for
veterans, servicemembers, and their families. Each day as a FRC is an
adventure in providing support that could, in all likelihood, otherwise
fall through the cracks given the complexity of some of these cases.
Much of what I provide is not quantifiable, and some of what I provide
would possibly not be missed by a client who did not expect a sound
safety net. However, I have come to realize that an intimate
understanding of a servicemember's or veteran's perspective of everyday
life within overlapping, impossibly complicated, delivery systems
equips me to find that (perhaps small) intervention that improves the
quality of life for those who risked everything for my freedom and my
grandchildren's quality of life. I never served in battle, but I am
honored to bring every minute of my personal and professional
experience to bear in caring for those who bore the battle.
Thank you again for the opportunity to share my experiences and
perspective with you, and I look forward to answering your questions.
Prepared Statement of Karen Gillette, RN, MSN, GNP,
Federal Recovery Coordinator, Providence, RI, Department of Veterans
Affairs Medical Center, U.S. Department of Veterans Affairs
Good morning Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Committee. My name is Karen Gillette, and I am a Federal
Recovery Coordinator (FRC) from Providence, Rhode Island. Thank you for
inviting me today to tell you what I do as a FRC to assist recovering
servicemembers, veterans and their families as they heal and return
home. My testimony will focus on my roles and responsibilities in the
service of my clients.
Overview
I have been a FRC since 2008. My current active caseload includes
55 clients, all in different stages of recovery and reintegration. Some
of my clients have been recently injured and are still being treated at
military treatment facilities, while others are receiving care at
private rehabilitation facilities. I have clients, now veterans, who
were injured several years ago and continue to need assistance with
veterans' benefits, case management issues at their local Department of
Veterans Affairs (VA) facility, vocational rehabilitation benefits, or
help finding community resources in their local area. In addition to my
caseload, I also have clients on my inactive case list that
occasionally contact me with questions or to just let me know how they
are doing.
My experience in this field stems from my clinical and
administrative experiences as a nurse practitioner and nurse executive,
and from the extensive Federal Recovery Coordination Program (FRCP)
training and education on veterans benefits programs, military
programs, TRICARE, social security, Department of Labor programs and VA
programs. FRCs attend quarterly training at different sites including
VA's polytrauma facilities around the country. We have met with the
staff at Walter Reed Army Medical Center, National Naval Medical
Center, Quantico, and at Veterans Benefits Administration (VBA)
Regional Offices. We have had training on mediation, coaching,
mentoring and motivational interviewing. My experience and training
have helped me to establish a good working relationship with families,
and to gain experience in the Veterans Health Administration (VHA)
system and a working knowledge of VBA policy and resources.
My caseload consists of referrals from many different sources.
Referrals come from VA case managers, military personnel, caregivers,
community and charitable organizations, and clients, who also refer
other Wounded Warriors to our program. I have Army Wounded Warrior
(AW2), Air Force Wounded Warrior (AFW2) and Marine District Injured
Support Cells (DISC) staff who ask me to assist with their clients
having problems with reintegration into the community. I also make sure
to ask these sources if there are any other cases they are aware of
where my services might be beneficial.
I currently work with case managers located in over 35 VA Medical
Centers (VAMC). These include Operation Enduring Freedom/Operation
Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) case managers,
polytrauma coordinators, spinal cord injury/disability coordinators,
community nurse coordinators, home-based primary care staff, social
workers in VA's community living centers, as well as health care
providers. We collaborate to share resources, suggestions and
information that meet the client's needs. I work closely with fee basis
staff and prosthetic department staff, speech therapists and other
members of the physical medicine and rehabilitation staff at local
VAMCs and clinics. I work with VBA personnel who manage the
compensation claims, vocational rehabilitation and fiduciary needs of
my clients at VBA sites around the country. Beyond VA, I work with
staff at the Social Security Administration, State disability and
Medicaid case managers and TRICARE and military nurse case managers on
a regular basis.
I stay in close contact with the different wounded warrior program
representatives, and we discuss resources and options that might be of
benefit to shared clients. We collaborate closely and make sure the
right person is doing what is needed. I work with recovery care
coordinators on some cases that we share. I usually focus on VHA and
VBA issues and the recovery care coordinators focus on military
administrative detail. Our collaboration is effective and
complementary.
As a FRC, I provide many informational briefings about the program
at national conferences. I have staffed FRCP booths at a variety of
meetings and conferences and have used that opportunity to discuss the
program with attendees. I attend Veterans Integrated Service Network-
level training and conferences in New England and try to stay in
contact with VA's polytrauma coordinators. I have also attended
military conferences to discuss the role of the FRC in a client's
treatment and
recovery.
I would now like to share with you some examples of the issues I
handle on a typical workday.
My workday begins by reviewing my work list, notes, tasks, phone
calls and e-mail so that I can prioritize the day's issues. My goal,
however, is to ensure that all of my clients are moving closer to the
goals established on their Federal Individual Recovery Plan (FIRP).
In one case, I collaborated with VA staff in getting a client with
severe traumatic brain injury (TBI) admitted to a VA polytrauma
rehabilitation facility to be evaluated for admission to an emerging
consciousness program. The family was relocating, and they were
interested in having the client receive care at a VAMC close to their
new home. The mother provides 24/7 in-home care for the client, who is
minimally conscious but has been showing increased awareness over the
last 6 months. I conducted a conference call with the closest VA
polytrauma team to the family's intended place of relocation to review
the client's case.
In another case, I spoke to an active duty servicemember's mother
about the servicemember's progress at a private rehabilitation
facility, and we discussed future possibilities with her for the next
phase of his recovery. I then called the servicemember's medical case
manager at the military treatment facility to discuss future transfer
plans for this client from the private rehabilitation facility back to
the military treatment facility, and then on to a VA polytrauma
facility. The medical case manager agreed to contact the family and
make travel arrangements for them, and to assist with accommodations at
a Fisher House.
I worked with an OEF/OIF/OND VBA case manager to resolve issues
related to a client's VBA compensation and pension rating process.
Prior to this, I had worked with VBA to get this client's rating file
moved to the seriously injured list to expedite the case. The client is
at a VA spinal cord injury/disability center. The case manager will
work with the family and the VBA rating official to ensure that the
client's claim moves forward.
I received a call from a veteran's family regarding their visit to
a private neurological residential center that I had located for them
as a possible site for the veteran's next phase of community re-
integration. This young veteran is a candidate for VA's TBI Assisted
Living pilot program. The family was very pleased with the site, which
was in the location of their choice. I provided the TBI-Assisted Living
pilot program administrator and the local VA with an update on the
family's visit, and they initiated the required contracting process.
I spoke to a case manager at a military treatment facility about a
new referral. The veteran had not used VA for heath care since a
stroke. In addition, the veteran's VBA Monthly Special Compensation had
recently been decreased, which resulted in the veteran having to
relocate across the country. I reviewed the veteran's rating letter and
found that the rating decrease was possibly due to inadequate
documentation provided to the rater. I began gathering information to
help educate the individual and the family about FRCP and to assist the
veteran with collecting the necessary documentation to support the
claim.
I called the Marine District Injured Support Cells in that area and
asked him to contact this former Marine as an additional support to the
family. I connected the veteran with the local OEF/OIF/OND care
management team, who then contacted the family to provide assistance.
I assisted an OEF/OIF team in finding a private substance abuse
rehabilitation program for a client who required a more controlled
environment than VA could provide.
I contacted a VBA regional OEF/OIF officer and asked for his
assistance in helping a client whose adapted car recently caught fire
and was inoperable. This family had been told that they were not
eligible for another auto grant. The VBA representative contacted the
family and worked on the issue with them.
I coordinated with multiple levels of leadership to expedite the
transfer of one of my clients from one VA community living center to
another.
These are just a few examples of what I do every day to assist my
clients. Most of my time is spent in making multiple phone calls,
writing and responding to e-mails and following-up to ensure that
things are progressing as they should. All of my activities are
documented in the FRCP data management system. I spend a lot of time
providing medical education to families and clients, as they are
sometimes reluctant to take up the health provider's time during a
clinic appointment time just to ask questions. I spend a lot of time on
the National Resource Directory looking for resources and opportunities
for my clients and their families.
Conclusion
In conclusion, in the 3 years I have worked as a Federal Recovery
Coordinator, I have established rapport with most of the stakeholders
involved in moving these catastrophically ill and injured
servicemembers and veterans into more stable and satisfactory life
situations. I have found that what appears to be a ``simple to
resolve'' situation can take multiple phone calls and e-mails to keep
the process moving forward towards resolution. It takes effective
communication with a variety of people to address my clients' complex
issues.
I assist my clients in navigating the intricate VA and military
health care systems. I have been able to assist many of my families in
connecting to the right resources at the right time, assist them with
getting their Social Security and VA claims completed, and connect them
with private charitable organizations that can meet some of their
financial needs. I provide support as relationships are established
with VA teams, increasing the veteran and family's trust and
willingness to choose VA as their health care provider. I am proud to
have served our country's veterans and servicemembers that have
sacrificed so much for our country.
Thank you for having me here today to share with you my
experiences, and I look forward to your questions.
Prepared Statement of Colonel John L. Mayer, USMC,
Commanding Officer, Wounded Warrior Regiment, U.S. Marine Corps, U.S.
Department of Defense
Chairwoman Buerkle, Ranking Member Michaud, and distinguished
Members of the Health Subcommittee, on behalf of the United States
Marine Corps, thank you for this opportunity to provide testimony on
interaction between the Marine Corps' Recovery Coordination Program
(RCP), which is executed by the Wounded Warrior Regiment (WWR), and the
Department of Veterans Affairs Federal Recovery Coordination Program
(FRCP), which is overseen by the DoD/VA Wounded, Ill, and Injured
Senior Oversight Committee. Many severely wounded, ill, and injured
(WII) Marines are unable to return to active duty and the Marine Corps
WWR works to ensure these Marines are postured for success as they
reintegrate to their communities. We fully recognize that reintegration
success is largely dependent upon the programs and services offered by
the Department of Veterans Affairs. As such, the WWR welcomes
opportunities to increase collaboration between the Department of
Defense and Department of Veterans Affairs and to integrate efforts
where appropriate.
The Marine Corps Wounded Warrior Regiment: Background and Assets
To provide the Subcommittee context on interaction between the
Marine Corps' RCP and the VA's FRCP, it is important to provide
background on the mission and scope of the WWR. Established in 2007,
the WWR was created to provide and facilitate non-medical care to WII
Marines, and Sailors attached to or in direct support of Marine units,
and their family members in order to assist them as they return to duty
or transition to civilian life. Whether wounded in combat, suffering
from an illness, or injured in the line of duty, the WWR does not make
distinctions for the purposes of care. The Regimental Headquarters
element, located in Quantico, VA, commands the operations of two
Wounded Warrior Battalions located at Camp Pendleton, CA and Camp
Lejeune, NC, and multiple detachments in locations around the globe,
including Military Treatment Facilities and at Department of Veterans
Affairs Polytrauma Rehabilitation Centers.
In just a few years, the WWR has quickly become a proven unit
providing WII Marines, their families, and caregivers coordinated non-
medical support. Some of the Regiment's primary care assets include: a
Resource and Support Center, the Sergeant Merlin German Wounded Warrior
Call Center, which extends support to Marines and families through
advocacy, resource identification and referral, information
distribution, and care coordination; Clinical Services Staff that
provide immediate assistance and referral for Marines with
psychological health issues and/or post traumatic stress or traumatic
brain injury; a Job Transition Cell, manned by Marines and
representatives of the Departments of Labor and Veterans Affairs; and
District Injured Support Cells (DISCs) located throughout the country
to conduct face-to-face visits and telephone outreach to WII Marine and
their families who are recovering or transitioning to their assigned
region.
Care Coordination: The Importance of Recovery Teams
The complexity of WII Marines' care requires a heightened level of
coordination between various medical and non-medical care providers.
There is no ``one size fits all'' approach to care and the Regiment
responds to this requirement by delivering a cross-section of services
and resources tailored to meet the specific needs of WII Marines and
their families. We determine the specific requirements to meet these
needs through the coordinated efforts of medical and non-medical care
providers who are part of our Marines' Recovery Teams. The Recovery
Team includes, but is not limited to, Marine Corps leadership; Section
Leaders who provide daily motivation and accountability; non-medical
care managers; medical case managers; and Recovery Care Coordinators
(RCCs). Recovery Team participation may be expanded depending on the
acuity of the Marine's case or the needs of the Marine and family and
may include the Primary Care Manager, mental health advisors, and the
Federal Recovery Coordinator (FRC).
Marine Corps Recovery Care Coordinators
The Marine Corps' RCCs are highly qualified and dedicated
individuals who serve as a point of contact for our WII Marines and
families, and they work hand-in-hand with the WWR's support staff.
Typically, our RCCs have case management experience, have college
degrees (some with master's degrees), prior military experience (the
majority are prior Marines), are combat veterans, and have military
leadership experience. We have found that this combination of
credentials provides our WII Marines and their families a high level of
support. For example, the WWR's 2010 Recovery Care Coordinator Survey
showed 81 percent of WII Marines and their family members were either
satisfied or very satisfied with the attributes pertaining to their RCC
(i.e., timeliness, availability, frequency of communication, advocating
for needs and goals, coordinating and monitoring medical and non-
medical care, and facilitating reintegration back into the community).
Moreover, of the respondents that stated they had an RCC, a very high
percentage (96 percent) reported that their RCC satisfied their
explained roles and responsibilities. This is particularly important,
as we know recovering servicemembers and their families can be confused
by myriad of case managers who may become involved in their recoveries.
Our Recovery Care Coordinators are located at Military Treatment
Facilities, VA Polytrauma Centers, and are imbedded within the Regiment
and Battalions to provide immediate, face-to-face support to our WII
Marines and their families. Along with their unique ties to the Marine
Corps, this close proximity to Regimental staff precludes logistical
challenges, improves information sharing, facilitates care
coordination, and enhances the quality of care provided. Per WWR
policy, which comports with Federal statute and regulation, RCCs are
assigned to certain active duty (typically seriously ill/injured and
severely ill/injured) WII Marines. RCC caseloads do not exceed the
prescribed Department of Defense Instruction 40:1 ratio. Assignment
priority is given to Marines who are joined to the WWR; however, the
Marine Corps' RCP is available to WII Marines and their families
whether they are assigned to the WWR or remain with their operational
units. A key attribute of the Marine Corps recovery care program is
that it allows WII Marines to remain with their parent commands so long
as their medical conditions allow and their parent command can support
their needs. Accordingly, our RCCs allow our WII Marines to ``stay in
the fight'' by providing assistance to WII Marines who are not joined
to the WWR.
Whenever possible, the RCC is one of the first points of contact
the Marine and family has with the WWR support network. Usually within
72 hours of assignment, RCCs engage their WII Marine and family and
immediately begin development of their Comprehensive Transition Plan
(CTP). RCCs help Marines with immediate needs and set goals for the
long-term. RCCs perform comprehensive needs assessments with their
Marines and families, which takes into consideration various recovery
components such as employment, housing, financing, counseling, family
support, the disability evaluation process, and more. The information
derived from the needs assessment becomes the basis for the Marine's
CTP and is often referred to as a ``life map'' for the recovering
Marine and family. It reflects their medical and non-medical goals and
milestones from recovery and rehabilitation to community reintegration.
The CTP is updated frequently to reflect changes in the Marine's
health, financial situation, or transition goals. A Marine's outlook or
goals for their future may be somewhat limited during the recovery
phase and will improve and become more focused when they start
rehabilitation, get involved in reconditioning sports, and begin to
accomplish what may have at one time seemed to be impossible. The RCC,
in coordination with the Marine Corps leadership and other Recovery
Team members, will regularly reassess the Marine's mental, physical,
and emotional state to ensure that their transition plan reflects their
progress.
For Marines who move to veteran status and require continued
transition support, RCCs coordinate the transfer of their case to the
WWR's DISCs for continued support. Additionally, when a catastrophic
WII Marine is preparing for transition to veteran status, the RCC may
coordinate transfer of the Marine's case to an FRC.
RCC-FRC Collaboration
The Marine Corps fully recognizes the potential of the FRCP and
where appropriate, we engage FRCs to ensure our severely injured
Marines who are approaching veteran status receive their support.
Across the country, we have situations where RCCs are working with FRCs
on behalf of our severely WII Marines who are approaching veteran
status. Especially for our Marines who are at VA Polytrauma Centers,
the FRC provides a valuable support resource to our RCCs.
As the Marine Corps continues to standardize its RCP, we look for
opportunities to establish practices with external programs, to include
the FRCP, to enhance the recoveries of our seriously injured Marines
and their families. Additionally, we look forward to collaboration and
leveraging best practices. The Marine Corps actively participated in
the March 2011 Wounded Warrior Care Coordination Summit, which included
a working group on Federal Recovery Coordination Program/Recovery
Coordination Program Collaboration. We also regularly coordinate with
the other services' wounded warrior programs to identify best practices
and improve care. We will continue to work with VA, DoD, our sister
services and all other stakeholders to ensure care provided to our WII
servicemembers and their families is complementary, not duplicative,
and fulfills our missions to posture those we serve for recovery and
transition success, free of unnecessary bureaucracy.
Conclusion
In his 2010 Planning Guidance, the Commandant of the Marine Corps,
General James F. Amos, pledged to ``enhance the capabilities of the
Wounded Warrior Regiment to provide added care and support to our
wounded, injured and ill.'' This is in keeping with the Marine Corps'
enduring pledge to take care of their own. We are proud of our ``Once a
Marine, always a Marine'' ethos and are grateful for the support of
this Committee and its dedication to the well being of the Marines who
have so proudly served our great Nation.
Prepared Statement of Colonel Gregory Gadson, USA, Director,
U.S. Army Wounded Warrior Program, U.S. Department of Defense
Thank you, Chairwoman Buerkle, Ranking Member Michaud, and all
Members of the Subcommittee for inviting me to appear today. I am
honored to be here. As a wounded warrior myself, I wish to thank all
the Members of the Committee for their interest in the health and well-
being of wounded, ill, and injured servicemembers and veterans.
The lead proponent for the Army's Warrior Care and Transition
Program (WCTP) is the Warrior Transition Command (WTC), under the
command of Brigadier General Darryl A. Williams. The WTC supports the
Army's commitment to the rehabilitation and successful transition of
wounded, ill, and injured soldiers back to active duty or to veteran
status and ensures that non-clinical processes and programs that
support wounded, ill, and injured soldiers are integrated and optimized
throughout the Army. I am the director of the U.S. Army Wounded Warrior
Program, or AW2, an activity of WTC. AW2 supports severely wounded
soldiers, veterans, and families throughout their recovery and
transition, even when they separate from the Army. We do this through
more than 170 AW2 advocates who provide local, personalized support to
the more than 8,300 soldiers and veterans currently enrolled in the
program.
The Warrior Care and Transition Program (WCTP) also encompasses the
29 Warrior Transition Units, or WTUs located around the country and in
Europe where wounded, ill, and injured soldiers heal and prepare for
transition. I have AW2 advocates at each of these WTUs, and we identify
the severely wounded as quickly as possible, so AW2 can begin providing
support.
Each soldier in a WTU is assigned to a Triad of Care consisting of
a primary care manager, usually a physician, a nurse case manager, and
a squad leader. In addition, the WTUs have a multi-disciplinary
approach that includes a wide range of clinical and non-clinical
professionals, such as physical therapists, behavioral health
professionals, chaplains, social workers, and occupational therapists.
AW2 advocates work closely with each of these professionals in support
of the individual soldier.
A requirement for every servicemember in the Federal Recovery Care
Program is a comprehensive needs assessment, or Federal Individual
Recovery Plan. Within the WTUs we conduct this comprehensive needs
assessment through the development of what is referred to as a
Comprehensive Transition Plan or CTP. The CTP is not the Army's plan
for the soldier--it is the soldier's plan for him/herself. Each soldier
completes a CTP within 30 days of arriving at the WTU, in coordination
with the multi-disciplinary team. They set long- and short-term goals
in each of six domains of life: Family, Social, Spiritual, Emotional,
Career, and Physical. Our goal is to make sure each soldier is well-
prepared for the next phase of their lives, whether they return to the
force or transition to civilian life. The AW2 advocates are closely
involved in this process, including the periodic Focused Transition
Review meetings where the WTU commander gathers the soldier, family
member or caregiver, and the health care professionals involved in
caring for the soldier, and they discuss the soldier's progress.
Families are closely involved with the CTP process, and family is
one of the six domains of goal-setting in the CTP. Family members and
caregivers are invited to all of the Focused Transition Review meetings
and to all medical appointments, therapy treatments, informational
briefings, etc. AW2 advocates and squad leaders also work closely with
the families to make sure that their needs are met. When an AW2 soldier
separates from the Army and transitions to veteran status, an AW2
advocate continues to support the soldier/veteran and family just as
they did when the soldier was in the WTU.
Another key component of WCTP is the Soldier Family Assistance
Centers, or SFACs. SFACs are operated by the Army's Installation
Management Command, and they are on-site at WTUs. They bring together
many of the programs and experts the WTU soldiers and families need to
provide assistance with everything from childcare and lodging to
arranging for Department of Veterans Affairs (VA) care and benefits.
AW2 advocates work closely with Federal Recovery Coordinators (FRC)
where they are available. As you know, FRCs are currently located in 10
military and VA medical facilities. There are more than 170 AW2
advocates on my staff, spread throughout the country, Germany, and five
U.S. territories. They are present at 60 VA facilities and 29 WTUs, and
those that are co-located with FRCs do coordinate closely with them. We
have an open referral process where AW2 advocates and the Triad of Care
can refer soldiers and veterans to the FRC if we believe they may
qualify.
The Federal Recovery Coordination Program (FRCP) has the potential
to facilitate positive, quality integration across the various programs
throughout the Federal Government that support severely wounded, ill,
and injured servicemembers. It has the potential to be a critical
resource for these servicemembers and their families.
The AW2 advocates on my staff report having positive relationships
with the FRCs and indicate that these FRCs are well trained, proficient
professionals. The FRCs are well-versed in the resources provided by
the VA and the resources available in their regions. They are also very
knowledgeable about policies that can support the needs of the wounded,
ill, and injured population.
I also want to discuss GAO's recommended actions for the FRCP. As
you have read in the comments section of the GAO report, the Honorable
John Campbell, Deputy Assistant Secretary of Defense for Wounded
Warrior Care and Transition Policy committed the Department of Defense
to continuing to collaborate with the VA on these issues. A Joint
Department of Defense (DoD)/VA Committee has been formed to study how
to combine or integrate recovery coordination efforts for wounded, ill,
and injured servicemembers, veterans, and families.
Recommendation 1 of the GAO's report discusses establishing
adequate internal controls regarding FRC's enrollment decisions. This
is not a problem at AW2. While FRCs are afforded broad discretion in
determining which servicemembers are admitted to the program, AW2 has
very clear eligibility criteria. We accept and support soldiers who
receive an Army disability rating of at least 30 percent for a single
injury since September 11, 2001, regardless of whether that injury was
sustained in combat or not. In 2009, based on AW2's understanding of
the long-term needs of this population, we expanded that criterion. We
now also accept Soldiers who receive a combined Army disability rating
of 50 percent or greater for conditions that are the result of combat
or are combat-related. All AW2 eligibility decisions are made at the
headquarters level, by a team of nurses and a Masters-level behavioral
health professional who closely review all eligibility requests. We
often accept soldiers before they receive their formal disability
ratings, if the nature of their injuries makes it very clear that they
will meet the AW2 eligibility requirements.
The GAO's next recommendation discusses the FRCP's efforts to
manage the workloads of individual FRCs based on the complexity of the
services needed. At AW2, we pay very close attention to the caseloads
of AW2 advocates. The average caseload is 1 to 50, but each soldier
requires a different level of support, depending on where he or she is
in the recovery and transition process, to include veterans.
For example, AW2 veteran Kortney Clemons is a severely wounded
veteran who no longer requires a significant level of AW2 support. He
was a combat medic in Iraq, and he stepped on an IED just 5 days before
his enlistment was up. He lost his right leg above the knee. Kortney
has been out of the Army for more than 5 years. He's gone on to become
the national Paralympic champion in the 100 and 200 meter dash and is
training for the Paralympic Games in London next year. He is currently
enrolled in a Masters Degree program through the AW2 Education
Initiative, a partnership between my program, the U.S. Army Training
and Doctrine Command, and the University of Kansas. He no longer
requires the same level of support from an AW2 advocate as he did when
he was first injured.
AW2 recognizes that many of the soldiers and veterans we support
become more independent as they heal and transition to the next phase
of their lives. We developed the Lifecycle Case Management Plan, or
LCMP, to help AW2 advocates identify the level of support each soldier
needs. There are four phases. When the soldier/veteran requires a
significant level of support, AW2 calls them at least once a month,
sometimes more, if their personal situation requires it. As they
progress and become more independent, we call them less frequently,
every 60 or 90 days in the next two phases. In the last phase, where
Kortney is, we only call them every 180 days. I am proud to say that I
personally ``graduated'' to the last phase of the LCMP in March.
Soldiers and veterans can always call their AW2 advocate or the AW2
call center if they need support and we will be here for them. This
initiative allows the AW2 advocates to focus on those with a more
immediate need for their support, such as the most recently injured,
those going through the Medical Evaluation Board, or those facing
significant personal or medical challenges.
GAO's third recommendation addresses the FRCP's decision-making
process for determining when and how many FRCs the VA should hire. AW2
faces some of the same challenges as the FRCP on this issue. It is
difficult to predict how many additional soldiers will qualify for our
program in the future. In 2010, we accepted more than 2,000 new
soldiers into the program. On average, that means we added one
additional Ssldier to each AW2 advocate's caseload every month. We are
increasing our staff levels as quickly as possible. This fact makes it
even more important that we ensure the AW2 program is run as
efficiently as possible. The LCMP allows us to manage the rate at which
additional advocates are required.
One way we have dealt with the need for more advocates is to
strengthen the communication between AW2 soldiers, veterans and
families so that they educate and support each other. We have launched
peer-to-peer tools to enable the AW2 soldiers, veterans, and families
to communicate with one another. We have established a blog and a
Facebook account to facilitate a conversation among the
population online.
GAO's final recommendation calls for the FRCP to develop and
document a clear rationale for the placement of FRCs, including a
systematic analysis of data to support these decisions. At AW2, we
evaluate our staffing on a quarterly basis. We make advocate
assignments by zip codes and place them where we have the greatest
populations of AW2 soldiers and veterans. We have reassigned some of
the contract positions based on the locations of the population we
support. As I mentioned before, we have 170 AW2 advocates. Sixty of
them are at VA facilities and at each of the 29 WTUs, to provide local,
personalized support to AW2 soldiers, veterans, and families where they
are. I would submit that aligning FRCs in a similar manner regionally
would better serve both them and the servicemembers for whom they are
responsible.
There are a couple of other items in the GAO report that I want to
acknowledge. One is access to office space and technology at various VA
facilities. Many AW2 advocates on my staff have experienced similar
challenges finding a private space to conduct sensitive conversations
and getting access to technology. AW2 now has a designated liaison with
the VA and this has significantly helped the situation. There are still
individual challenges but by facilitating that relationship and
proactively talking to regional VA facilities before the new advocate
arrives we have been able to mitigate this problem.
The GAO report also highlighted the challenges in information
sharing between the DoD and VA. We recognize the importance of this
challenge. For over a year now, the Warrior Transition Command has been
developing automated systems that are part of an integrated system for
tracking and managing the care of soldiers and veterans. The CTP
mentioned previously is a fully automated process which provides
managers at every level the ability to thoroughly analyze, in real
time, the performance of staff in the development and updating of these
plans. Currently being completed for implementation later this year is
the central module of the system referred to as the Automated Warrior
Care and Tracking System; the automated CTP will interface with this
module which contains the history of each soldier and veterans care.
The Executive Director of the FRCP and the Deputy Under Secretary
of Defense for Wounded Warrior Care and Transition Policy are co-
chairing an information sharing initiative (ISI) to support
coordination of non-clinical care for seriously wounded, ill and
injured Operation Enduring Freedom and Operation Iraqi Freedom (now
Operation New Dawn) servicemembers, veterans, and families. The Army
has been an active participant in this joint DoD/VA ISI. The ISI will
enable sharing of authoritative data electronically between DoD, VA,
and the Social Security Administration case and care management
systems. This will eliminate resource-intensive and error-prone work-
arounds. A pilot for this initiative is underway for the bi-lateral
sharing of benefit and case manager information. Further efforts will
include such items as select care plan information and appointment and
calendar functions. These efforts will significantly improve the
challenges to information sharing between the agencies.
In closing, I again thank you, Madam Chairman and Ranking Member
Michaud, for inviting me here today and for listening to my testimony
about the Federal Recovery Coordination Program. I appreciate your
attention to wounded, ill, and injured servicemembers, veterans, and
their families, and I know that we share the same goal of providing the
best possible services to these individuals who have sacrificed so
much.
Statement of Adrian Atizado,
Assistant National Legislative Director, Disabled American Veterans
Madam Chairwoman and Members of the Subcommittee on Health:
On behalf of the more than 1.4 million members of the Disabled
American Veterans (DAV) and our Auxiliary members, thank you for
inviting our organization to submit testimony to your Subcommittee
today on the topic of the Federal Recovery Coordination Program (FRCP),
and in particular your continuing focus on whether the program has
begun to fulfill its promise to those who have made major sacrifices
while serving our Nation in hostile combat deployments during the
worldwide war on terror.
To examine the FRCP for the purposes of this hearing, it is
important to view this program in context. As this Subcommittee is
aware, the Department of Veterans Affairs (VA) has the authority to
coordinate care with the Department of Defense (DoD) pursuant to
sections 523(a) and 8111 of title 38, United States Code (U.S.C.). Both
Departments are also required under Public Law 107-772, which amended
section 8111 to establish an interagency committee to recommend
strategic direction for the joint coordination and sharing of health
care resources and efforts between and within the two Departments.
VA's current transition, care and case management program can be
traced back to 2003 with the designation at each VA facility of a
Combat Veteran Point of Contact and clinically trained Combat Case
Manager. These individuals were responsible for receiving and
expediting transfers of servicemembers from the DoD to VA health care
systems, VA took steps to modify and grow its transition, care and case
coordination program. Early seamless transition efforts were limited to
VA and the Army--specifically, with Walter Reed Army Medical Center
(WRAMC), Brooke, and Eisenhower and Madigan Army Medical Centers--and
placement of full time Veterans Health Administration (VHA) social
workers and Veterans Benefits Administration (VBA) representatives.
The VA Office of Seamless Transition was established in January
2005, staffed by VHA and VBA staff and DoD's Disabled Soldier Liaison
Team, where information about servicemembers to be served by the office
was relayed to VA from DoD in the form of a Physical Evaluation Board
list of those who were medical separated or retired. Then, as now, data
flow from DoD to VA and patient tracking were identified
challenges.\1,\ \2\
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\1\ http://www.urbanhealthcast.com/NAADPC/
SlidesSeamlessTransition.pdf.
\2\ U.S. Government Accountability Office. Testimony before the
House Committee on Veterans' Affairs, GAO-05-1052T, September 28, 2005.
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Section 302 of Public Laws 108-422 and 108-447 required VA to
designate centers for research, education, and clinical activities on
complex multi-trauma associated with combat injuries. In June 2005, VA
designated four Polytrauma Rehabilitation Centers (PRCs) to be co-
located with the four existing Traumatic Brain Injury (TBI) Lead
Centers. In fact, these TBI Lead Centers are not commonly referred to
as Polytrauma Centers.
Also in June 2005, VA's policy for the polytrauma system of care
was issued, which included the infrastructure designation of Level I
PRCs, Level II Polytrauma Network Sites, Level III Polytrauma Support
Clinic Teams, and Level IV Polytrauma Points of Contact. Staff at these
levels include the PRC Clinical Case Managers and PRC Social Work Case
Managers, OEF/OIF Program Manager, Transition Patient Advocates, OEF/
OIF Program Manager, OEF/OIF Nurse and Social Worker Case Managers for
clinical and psychological care management respectively, OEF/OIF VBA
Counselor, VA Liaisons at military treatment facilities, and other case
and care managers (Women Veterans, Spinal Cord Injured, Visual
Impairment Service Team, Polytrauma Support Clinic Teams).\3\
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\3\ Department of Veterans Affairs, Veterans Health Administration,
VHA Directive 2005-024, Polytrauma Rehabilitation Centers, June 8,
2005; Department of Veterans Affairs, Veterans Health Administration,
VHA Directive 2006-043, Social Work Case Management in VHA Polytrauma
Centers, July 10 2006. (Rescinded VHA Directive 2005-024, June 8, 2005;
Department of Veterans Affairs, Veterans Health Administration, VHA
Directive 2009-028, Polytrauma-Traumatic Brain Injury (TBI) System of
Care, June 2, 2009;
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DoD's current transition, care and case management program, the
Wounded Warrior Care and Transition Policy program, is based on
recommendations made by commissions and other review groups\4\ that
were convened before and after the deficiencies at WRAMC came to light
in February 2007.
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\4\ Inspector General Review of DoD/VA Interagency Care Transition,
DoD Task Force on Mental Health, the Independent Review Group, the
Veterans Disability Benefits Commission, the President's Interagency
Task Force on Returning Global War on Terror Heroes, and Commission on
Care for America's Returning Wounded Warriors.
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Taken from the July 2007 report of President's Commission on Care
for America's Returning Wounded Warriors, the FRCP was implemented
through two Memoranda of Understanding dated August 31, 2007, and
October 15, 2007.\5\ However, it should be noted that developing the
FRCP occurred simultaneously with legislation subsequently enacted in
January 2008 as Public Law 110-181, directing VA and DoD to ``jointly
develop and implement comprehensive policies on the care, management,
and transition of recovering servicemembers.''
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\5\ Accessible at: http://www.tricare.mil/DVPCO/downloads/
Final%20MOU%20VA%20DoD.pdf.
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The law's requirements specifically include:
creating the Recovery Coordination Program (RCP) for
recovering servicemembers and their families;
developing uniform program for assignment, training,
placement, supervision of Recovery Care Coordinators, Medical Care Case
Managers, and Non-Medical Care Managers;
developing content and uniform standards for the
Comprehensive Recovery Plan, including uniform policies, procedures,
and criteria for referrals; and
developing uniform guidelines to provide support for
family members of RSMs.
Moreover, deployment of the FRCP program occurred during the
development of what is now the current state of VA and DoD care and
case management programs.
DoD's current Wounded Warrior Care and Transition Policy program,
now includes the FRCP, Recovery Coordination Program, Transition
Assistance Program, the National Resource Directory, and Wounded
Warrior Employment initiatives. Within the Recovery Coordination
Program, front line service is provided by recovery care coordinators,
medical and non-medical care managers, and an individualized recovery
or transition plan. Each military service has its own program
implementing Public Law 110-181 and DoD's four cornerstones and ten
steps of care, management and transition Coordination policy.\6\ These
programs include the Army Wounded Warrior Program, Marine Wounded
Warrior Regiment Recovery Coordination Program, the Navy's Safe Harbor
program, and the Air Force Wounded Warrior program.\7\ In addition to
direct support and assistance to servicemembers, each military service
has programs in place to support the families of wounded, ill or
injured servicemembers.
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\6\ Department of Defense Instruction 6025.20, Medical Management
Programs in the Direct Care System and Remote Areas, January 5, 2006;
Department of Defense Instruction 1300.24, Recovery Coordination
Program (RCP), November 24, 2009; Department of Defense, The
Foundations of Care, Management and Transition Support for Recovering
Servicemembers and Their Families, September 15, 2008.
\7\ Established in 2004, AW2 assigns an AW2 advocate, and the
Warrior Transition Units (WTUs) where a servicemember is assigned a
triad of care and development of a Comprehensive Transition Plan. The
triad includes a primary care manager (normally a physician), nurse
case manager, and squad leader--who coordinate their care with other
clinical and non-clinical professionals. WTUs also have platoon
sergeants to assist where needed. The Marine Wounded Warrior Regiment
commands the East and West Wounded Warrior Battalions and other
detachments and uses Recovery Care Coordinators to help define and meet
a member's recovery plan as well as District Injured Support Cells to
assist recovering mobilized reserve Marines. Established in 2005 the
Safe Harbor Program offers two levels of support: Non-medical case
managers to support and assist member and family needs, and Recovery
Care Coordinators who oversee and assist with the member's
Comprehensive Recovery Plan. The Air Force Warrior and Survivor Care
Program initially depended on family liaison officers and community
readiness consultants to assist in community reintegration. Air Force
Recovery Care Coordinators were added whose area of responsibility is
regionalized and who work closely with family liaison officers, patient
liaison officers, and medical case managers.
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As this Subcommittee is well aware, this coordination program, like
some of its sister efforts, was born in controversy. In fact we believe
most of the efforts to create coordinator positions came about on
discovery of gaps in services or difficulties in conducting a seamless
transition for the wounded. In particular, when the scandal at WRAMC
erupted in February 2007, and a number of Federal agencies, task forces
and commissions reviewed the transition process of injured
servicemembers, it became obvious that our government was not fully
supporting the rights and benefits of seriously disabled veterans from
Iraq and Afghanistan in repatriating to their homes and families in an
orderly way.
At WRAMC and elsewhere, hundreds of patients were unnecessarily
being held in ``medical holds,'' with little prospect of discharge or
retirement, and with many of their families also held in that same
limbo. Per diem support and living conditions for family members were
woefully inadequate. Information was scarce or confusing. Support
services tailored to individual needs were thin to nonexistent, but
expectations on these troops were very high that they remain in an
organized and focused military posture while dealing with their medical
responsibilities.
Since the program's inception, servicemembers, veterans and their
loved ones recognize the assistance they receive from their assigned
FRC is invaluable, which is a testament to the FRCP. Further, DAV is
encouraged that the FRCP has been expanded over the years; however, in
previous testimony our organization has provided to Congress, because
the FRCP was developed after VA's polytrauma system of care and before
DoD's Wounded Warrior Care and Transition Policy program, we believe
this is the source of many of our questions that remain regarding the
effectiveness of the FRCP in meeting the need of severely injured
servicemembers.
With so many coordinators, clinical and non-clinical case managers
created in the development of VA and DoD's transition programs, we
sought out basic information to validate these programs are working as
intended. In April 2008, we testified the data we were receiving at
that time indicated that for each injured servicemember who is
currently enrolled in the FRCP, as many as 6 FRCs may be assigned.\8\ A
number of the families who are beneficiaries of this work have reported
that the advice they receive is often overlapping, redundant, confusing
and conflicting. Many of them seek a singularity of advice rather than
a chorus of competing advisors, to help them steer their paths toward
recovery.
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\8\ Update on VA and DoD Cooperation and Collaboration, Hearing
before the U.S. Senate Committee on Veterans' Affairs, 110th Congress
(2008).
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For as much emphasis as was placed on the need for a single
recovery coordinator and the heralding of the FRC as the ``ultimate
resource,'' DAV remains deeply concerned that the workload and
expansion of this program has not been accompanied by appropriate
resources being allocated.
DAV also raised concerns in testimony about integration of
Information Technology (IT) access within VA and the Military Training
Facility (MTF). VA and DoD, at least in the medical arena understand
the necessity of data systems and information support technologies.
These can serve an important role in facilitating the timely transfer
of essential information as patients traverse care systems and
settings. Moreover, VA and DoD are well aware of the complexity of
medical and non-medical needs of injured servicemembers, veterans and
their families, yet the IT support for the FRC remains inadequate.
Unfortunately, it appears our concerns are well founded as
portrayed in the March 2011 Government Accountability Office (GAO)
report titled, ``Federal Recovery Coordination Program Continues to
Expand but Faces Significant Challenges.''
If FRCs must, by definition, ensure that systemic barriers to care
and services are resolved at both the individual and the system level,
and the FRCP is to provide a system that transcends all boundaries to
coordinate servicemembers' and veterans' care and benefits through
recovery, rehabilitation, and reintegration into their home
communities,\9\ we believe it is only proper that commensurate
authority and resources to effect change and accomplish such a lofty
task must be provided.
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\9\ Department of Veterans Affairs, VA Handbook 0802, Federal
Recovery Coordination Program, March 23, 2011.
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Madam Chairwoman, in March of this year, the DoD held a Care
Coordination Summit that focused some of its work on the FRCP. A number
of recommendations are emerging from that consensus conference, based
on lessons learned from the past 3 years, that we believe warrant the
attention of this Subcommittee as you continue your oversight of the
FRCP. Among the findings and recommendations of the conference's
workgroups pertinent to this oversight hearing include the following:
FRCP/RCP Collaboration Recommendations:
Objective: Re-defined Care Coordination Program
Recommendations:
1. Eliminate category 1, 2, and 3 eligibility criteria. Establish
appropriate eligibility criteria for care coordination.
2. Improve integration within the Care Coordination Program.
3. Improve education and develop a strategic communications
process.
Objective: Improved integration of the Care Coordination Program
Recommendations:
1. Improve education and develop a strategic communications
process.
2. Provide interagency access to Information Technology systems.
3. Develop and implement a standardized referral and Intake
Process for the Care Coordination Program.
4. Consider geographic alignment of the FRCs.
5. Continue to expand and enhance the National Resource Directory.
A comprehensive report based on the outcome of the Wounded Warrior
Care Coordination Summit identifying best practices with actionable
recommendations will be developed with full support from the Wounded
Warrior Program Directors from each military service, the DoD Recovery
Coordination Program Director and the Executive Director of the VA
FRCP.
This report will be received by the Deputy Assistant Secretary of
Defense for Wounded Warrior Care and Transition Policy who will in turn
brief those actionable recommendations to be initiated prior to the end
of fiscal year 2011, to the Under Secretary of Defense for Personnel
and Readiness and to the Senior Oversight Committee.
We urge this Subcommittee to engage the appropriate office in the
Administration to ensure these recommendations made by front line
personnel of the VA and DoD care, management, and transition programs
receive due attention.
Madam Chairwoman, we hope the Subcommittee will work with its
counterpart in the Armed Services Committee to instill in both DoD and
VA a stronger interest in making the FRCP the program that was intended
by showing a stronger interest in implementing the recommendations of
its own consensus conference. Moving forcefully on these
recommendations may also bring VA into compliance with recommendations
of the Government Accountability Office in its March 2011 report to
Congress on the VA FRCP.
Madam Chairwoman, this concludes my testimony on behalf of Disabled
American Veterans.
Statement of the Military Officers Association of America
EXECUTIVE SUMMARY
Response to Recommendations of GAO Report on VA's Federal Recovery
Care Program (FRCP)
The Military Officers Association of America (MOAA) concurs with
the findings and recommendations in the Government Accountability
Office's (GAO) report, GAO-11-250, issued March 2011, titled, ``DoD and
VA Health Care; Federal Recovery Coordination Program Continues to
Expand but Faces Significant Challenges.'' Specifically, we agree that
VA should:
Establish systematic oversight of enrollment decisions;
Complete development of a workload assessment tool;
Document staffing decisions; and,
Develop and document a rationale for Federal Recovery
Coordinator (FRC) placement.
While we have seen great progress in VA's development and expansion
of the FRCP and just how effective these coordinators are based on
feedback from those wounded warriors and family members receiving these
services, MOAA believes, as GAO indicates in its report, that more
needs to be done in the area of program management and accountability.
Our Association continues to hear from frustrated, and sometimes
angry wounded warriors and their caregivers who are confused,
overwhelmed or intimidated by the FRCP. Some have been told they are
ineligible for an FRC, some were not informed they were eligible, and
others were constrained in accessing program services when and where
needed because of improper timing of receipt or coordination of the
information.
MOAA believes the absence of a way to systematically identify,
track FRCP eligibles and administer case management for this population
presents significant issues that need immediate attention.
Additional Recommendations
MOAA offers the following additional recommendations to improve the
FRCP:
Establish a consistent and uniform system of care
coordination in both VA and DoD that includes common terminology and
definitions, and provides a simpler way for wounded warriors and their
families to access and transition from DoD to VA programs.
Incorporate and integrate FRCP GAO recommendations and
future program enhancements into the newly establish VA primary
caregiver program mandated in the Caregivers and Veterans Omnibus
Health Services Act of 2010 to ensure consistent and uniform enrollment
criteria, terminology, and tracking procedures across the system.
Expand outreach and communication efforts in DoD and VA
medical and benefit systems to help increase awareness of the FRCP and
how to enroll eligible members and by conducting periodic needs
assessment surveys to get feedback from wounded warriors and their
families to improve the program and identify unmet needs.
__________
MADAM CHAIRMAN BUERKLE, RANKING MEMBER MICHAUD AND DISTINGUISHED
MEMBERS OF THE SUBCOMMITTEE, thank you for convening this important
hearing and allowing the Military Officers Association of America
(MOAA) to provide our observations concerning the GAO findings on the
FRCP and offer our recommendations.
MOAA thanks the Subcommittee for its leadership in recent years to
enhance programs in the VA for our wounded warriors and their families
and to provide necessary oversight to ensure progress continues to be
made in the area of health care and benefits so these individuals will
have the best quality of life possible over their lifetime.
GAO Report Findings
Many of the broad departmental issues plaguing both VA and DoD
systems are also impacting and limiting FRCP, and likely a number of
other wounded warrior programs, preventing them from effectively and
efficiently meeting the needs of our most vulnerable servicemembers and
disabled veterans who critically need these support services.
Specifically, GAO cites limitations in:
information sharing;
multiple VA and DoD case management programs for the same
wounded warriors;
Federal Recovery Coordinators (FRCs) relying on referrals
to identify eligible enrollees;
role confusion on the part of FRCs and DoD-Service
Recovery Care Coordinators and the numerous other case managers
overseeing wounded warrior care; and
issues of compliance, accountability and oversight within
the FRCP and across VA that inhibit uniformity and consistency of
operations to achieve a state of seamless transition.
MOAA is deeply troubled at GAO's finding that ``VA does not know
the number of severely wounded servicemembers in the Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts because `severely
wounded' is not a categorical definition used by the DoD or VA medical
and benefits programs. Further, that estimates of the size of the
severely wounded population vary depending on definitions and
methodology.''
While much has improved in the last 2 years as the FRCP expanded to
meet workload and improve seamless transition between the two programs,
MOAA is very concerned that VA and DoD systems still struggle with
basic terminology, policy, and management and technological system
differences after more than a decade of war.
The fact that the FRCP system was the first care coordination
program jointly developed by the two agencies would lead one to believe
that the program will be institutionalized and serve as a model for
other VA-DoD collaboration. But persistent problems with information
sharing and other long standing issues, to include the proliferation of
duplicative programs for recovering servicemembers and veterans, points
to a greater systemic problem well above the control of the Executive
Director of the FRCP.
The fact that VA must rely on referrals to identify eligible
individuals for the program makes the program vulnerable to
inconsistencies and inefficiencies, and those not identified are also
more likely to fall through the administrative cracks, resulting in
unintended medical consequences.
MOAA concurs with GAO's assessment of the program and urges the
Congress to require both VA and DoD to provide a report to this
Subcommittee on their progress in addressing these issues and
implementing the GAO recommendations.
Additional Recommendations for Consideration
MOAA believes that fixing the FRCP, in and of itself, will not
address the challenges facing the program. Multiple case management
systems and case managers assigned to wounded warriors and the
proliferation of programs and services in both the VA and DoD medical,
personnel and benefits systems have greatly confused and overwhelmed
wounded warriors and their families and have further stressed systems
already unable to meet the demands and fallout of war.
Recommend establishing a consistent and uniform system of care
coordination in both VA and DoD that includes common
terminology, definitions, and provides a simpler way for
wounded warriors and their families to access and transition
from one system to the other.
With the lessons learned from establishing and implementing the
FRCP and remaining issues that need to be addressed, VA has a unique
opportunity to apply these experiences and knowledge as it rolls out
the new primary caregiver program mandated in the Caregivers and
Veterans Omnibus Health Services Act of 2010. VA officials have stated
on a number of occasions their difficulty in identifying the population
that is eligible for the new caregiver services and benefits. If the
two systems are focusing on the same population of severely wounded,
then the transition process should be more streamlined and seamless.
We repeatedly hear from servicemembers and veterans who have an FRC
how great the program is and how the FRCs are an important lifeline.
Our Association believes it is important for DoD and service programs
to learn from VA and wounded warriors' experiences.
MOAA recommends VA incorporate FRCP GAO recommendations and future
program enhancements into the newly established VA primary
caregiver program to ensure consistent and uniform enrollment
criteria, terminology, and tracking procedures across the
system.
A recurring theme we hear from wounded warriors and family members
is the overwhelming amount of information and program services pushed
at them when they aren't ready to receive it, or are not in a position
to understand the information given to them, rather than making it
accessible when and where they need it. Disturbingly, others have never
received information or have been given only limited information about
programs like the FRCP or support services.
Wounded warriors and families have become increasingly vocal in
letting government program leaders know that they want to be consulted
and included in developing and establishing new programs rather than
having the administrators assume they know what is best for these
individuals. In other words, they want leaders to make greater efforts
to ask about and understand their needs before programs are developed
that don't fit them.
MOAA recommends expansion of outreach and communication efforts in DoD
and VA medical and benefit systems to help increase awareness
of the FRCP and how to enroll and by conducting periodic needs
assessment surveys to obtain and use feedback from wounded
warriors and their families to improve the program and identify
unmet needs.
Statement of Paralyzed Veterans of America
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to submit a statement for the record regarding
the progress and development of the Federal Recovery Coordination
Program (FRCP).
For more than 65 years it has been PVA's mission to help
catastrophically disabled veterans and their families obtain health
care and benefits services from the Department of Veterans Affairs
(VA), and provide support during the rehabilitative process to ensure
that all disabled veterans have the opportunity to build bright,
productive futures. It is for this reason that PVA strongly supports
the FRCP, and appreciates the Subcommittee's continued work on
improving the transition from active duty to veteran status for
severely injured, ill, or wounded veterans and servicemembers.
The FRCP was created as a joint program between VA and the
Department of Defense (DoD) to provide severely injured, ill, or
wounded servicemembers and veterans with individualized assistance
obtaining health care and benefits, and managing rehabilitation and
reintegration into civilian life. Through the program, veterans and
servicemembers are assigned a Federal Recovery Coordinator (FRC) and
create a Federal Individual Recovery Plan that consists of long-term
goals for the veteran and his or her family members. Such a plan
motivates veterans to fight through the initial difficulties of
adjusting to life after a catastrophic injury.
The purpose of today's hearing is to assess the progress and
challenges of the FRCP and identify potential ways in which the program
can be improved in order to fulfill its mission. In the past year, the
FRCP has made changes to enhance service delivery and expand its
outreach; however, more work must be done in order to adequately meet
the needs of veterans. Specifically, PVA believes that VA, DoD, and
Congress must work together to address challenges in the areas of
continuity of care, care coordination, and program awareness in order
to make a difference in the lives of those that have made the ultimate
sacrifice for our country.
Continuity of Care
A primary component of the FRCP is continuity of care. As it
relates to the FRCP, we believe that continuity of care means providing
veterans and servicemembers with individualized care that is
facilitated by an assigned primary Federal Recovery Coordinator (FRC)
who maintains a working relationship with the veteran and his or her
family to help manage a successful transition into civilian life after
an illness or injury.
PVA believes that one way in which continuity of care can be
improved within the FRCP is to ensure that FRCs remain in contact with
veterans not only during the initial phases of enrollment and
administration of the Federal Individual Recovery Plan, but also after
the veteran has become reintegrated in his or her community setting and
home. PVA believes it of extreme importance that FRCs keep in touch
with veterans and their families at this point to ensure that they are
adjusting to life after a disability, and providing information when
necessary to make certain that the veteran is aware of VA and DoD
benefits and services that may be beneficial to him or her as
utilization of the FRCP lessens.
In support of continuity of care, VA and DoD must also work to
create a system that monitors and manages the level of complexity and
size of FRC caseloads. As it is a goal of the FRCP to meet the
individualized needs of veterans and servicemembers, each case will be
unique and require different levels of attention. These factors must be
taken into consideration if FRCs are expected to provide timely quality
assistance that is truly helpful to veterans and their families.
In conjunction with FRC caseloads, the staffing of FRCs is another
area of concern that must be assessed to determine if current staffing
levels are adequate to meet veterans' needs. In a recent study
conducted by the Government Accountability Office (GAO) it was reported
that ``the FRCP faces challenges in determining staffing needs and has
not clearly defined or documented its process for managing FRC
caseloads . . . '' \1\ With a limited number of FRCs, issues involving
transportation and distance have the potential to hinder access to care
and resources for many veterans in rural areas, and thus, become
threats to continuity of care. PVA encourages VA to develop an outreach
strategy for veterans living in rural areas to make certain that they
are aware of the FRCP and have access to a FRC if necessary. We also
strongly recommend that VA develop a system to monitor and measure the
complexity and size of FRC caseloads. We ask that as the program
expands, VA, DoD, and Congress consider placing FRCs in locations where
veterans with disabilities are already seeking services such as VA
spinal cord injury centers or amputation centers of care.
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\1\ United States Government Accountability Office, Report to
Congressional Requestors: ``DoD and VA Health Care: Federal Recovery
Coordination Program Continues to Expand but Faces Significant
Challenges.'' March 2011; GAO-11-250.
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Care Coordination
It is important to remember that veterans participating in the FRCP
are also utilizing a multiplicity of other services from both VA and
DoD. Care coordination of all the services and programs that a veteran
chooses to utilize is extremely important for the success of the FRCP.
In The Independent Budget for FY 2012--co-authored by PVA, AMVETS,
Disabled American Veterans, and Veterans of Foreign Wars--it was
reported that ``. . . veterans transitioning from the DoD to VA who are
not assisted by the FRCP may be forced to interact with as many as five
VA representatives . . . '' \2\ Interaction with so many different
points of contact can be burdensome and overwhelming for veterans and
their families and lead to disengagement of not only the FRCP, but
other programs and services as well.
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\2\ The Independent Budget, ``The Continuing Challenge of Caring
for War Veterans and Aiding Them in Their Transition to Civilian
Life,'' pp. 91; 2011.
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On the contrary, when a veteran participates in the FRCP, the FRC
is familiar with these various services and programs and can help the
veteran better manage the multiple areas of care. Therefore, it is
vital for FRCs to be fully aware of the different programs and services
available to FRCP participants to avoid a duplication of efforts and
conflicting information that can lead to ``information overload'' and
confusion for veterans and servicemembers.
With regard to VA health care, the Veterans Health Administration
is currently undergoing a change in the way it delivers health care to
veterans by utilizing patient aligned care teams (PACT). PACT is
designed to provide patient-centered care through a team-based approach
that emphasizes care coordination across disciplines. PVA encourages
the FRCP leadership to work closely with the VA Office of Patient
Centered Care and Cultural Transformation since FRCs serve as an
information resource during the medical recovery process and the PACTs
will be making FRCP referrals.
Additionally, in support of care coordination, PVA hopes that FRCs
will reach out to the service officers and advocates who represent
various veteran service organizations and work with veterans in a
similar capacity on a daily basis. PVA has a network of National
Service Offices within VA that provide services to paralyzed veterans,
their families, and disabled veterans. These services range from
bedside visits to guidance in the VA claims process to legal
representation for appealing denied claims.
In fact, we recently received multiple reports describing close
working relationships between PVA's Senior Benefits Advocates and FRCs.
Our Senior Benefit Advocates and the FRCs work together on a daily
basis to assist veterans and their families. National Service Officers
can be a great resource to the FRC for referrals, information on VA
benefits and programs, and getting the word out about the FRCP within
the veteran community.
Program Awareness Among Veterans
Making sure that veterans and servicemembers, as well as their
families and caregivers, are aware of the FRCP has proven to be a
continuous challenge. While participation numbers are growing, FRCP
leadership must work to keep information about the program circulating
throughout the veteran and military communities. This can best be
accomplished as a joint effort that incorporates the different offices
and departments across both the VA and DoD.
Information posters and pamphlets should be made available to
veterans and servicemembers when they visit other VA and DoD offices to
promote the FRCP. Such educational literature would be useful not only
for the veteran or servicemember, but for their families and caregivers
as well. As previously mentioned, veterans participate in many VA
programs, but it is often a loved one or caregiver who is helping
manage and coordinate the various services of care and who could
significantly benefit from the help of an FRC.
Collaboration between FRCP staff and specialized services teams is
another way to reach the targeted population that can benefit from FRCP
services. The referral criteria for the FRCP includes veterans and
servicemembers who have sustained a spinal cord injury, amputation,
blindness or vision limitations, traumatic brain injury, post-traumatic
stress disorder, burns, and those considered at risk for psychosocial
complications--all areas included in VA's system of specialized
services. Therefore, it is only logical for the FRCP to work with these
specialty teams to promote the FRCP, and educate veterans entering VA
specialized systems of care on the FRCP services and benefits.
In conclusion, PVA urges continued Congressional oversight of this
extremely important program and recommends that FRCP leadership
periodically survey veterans and servicemembers, and their families, to
identify areas for improvement. As the FRCP is a new program, there are
numerous lessons to be learned and an abundance of opportunities for
development.
PVA appreciates the emphasis this Subcommittee has placed on
reviewing the care being provided to the most severely disabled
veterans and servicemembers. Navigating through America's two largest
bureaucracies is a daunting task, but it can be particularly
overwhelming when doing so after incurring a catastrophic injury such
as a spinal cord injury, amputation, or as a polytrauma patient.
Providing veterans with professional guidance and stability during this
process gives them the resources to make informed decisions involving
their health care and benefits and focus on their recovery and future
endeavors.
PVA would like to once again thank this Subcommittee for the
opportunity to submit a statement for the record. We look forward to
working with you to continue to improve the Federal Recovery
Coordination Program. Thank you.
Statement of Wounded Warrior Project
Chairwoman Buerkle, Ranking Member Michaud and Members of the
Subcommittee:
In presenting our policy agenda in March at a joint hearing before
the full House and Senate Veterans Affairs Committee, Wounded Warrior
Project recommended that the Committees review the operation and
effectiveness of the many programs Congress created to improve
warriors' transition from military service to civilian status. The
Federal Recovery Coordination Program may be among the most important
of those initiatives to our warriors and their families.
The program has its roots in the President's Commission on the Care
of America's Returning Wounded Warriors (the Dole-Shalala Commission),
which found that the system of care, services, and benefits created to
assist those who had been injured was too complex to navigate alone.
The Commission recommended the creation of ``recovery coordinators''
or, in the words of the father of a severely wounded Marine, ``a case
manager to manage my case managers.'' Ultimately, the National Defense
Authorization Act of 2008 (NDAA 2008) directed the Departments of
Defense (DoD) and Veterans Affairs (VA) to develop and implement a
comprehensive policy to improve care, management and transition of
recovering servicemembers and their families, to include the
development of comprehensive recovery plans, and the assignment of a
recovery care coordinator for each recovering servicemember.\1\ Working
jointly, DoD and VA entered into a memorandum of understanding
establishing a joint VA-DoD Federal Recovery Coordination Program to
assist those with category 3 injuries--those with a severe or
catastrophic injury or illness who are highly unlikely to return to
active duty and will most likely be medically separated. (A separate
DoD Recovery Coordinator Program was designed for those with category 2
injuries who might or might not return to duty.)
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\1\ Public Law 110-181, sec. 1611.
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In WWP's view, the Federal Recovery Coordination Program is a too-
rare instance of a holistic, integrated effort to help injured veterans
thrive again. The unique contributions--both medical and non-medical--
that Federal recovery coordinators are making in facilitating wounded
warriors' care-coordination and reintegration underscores the
importance of ensuring that this program reaches all who need that
help, and that it operate as effectively as possible. But while Federal
Recovery Coordinators provide extraordinary assistance to warriors and
their families, overarching systemic problems must be addressed to
ensure that the program fully meets its objectives.
GAO Identifies Systemic Problems
The General Accountability Office's recent report on the program
identifies important issues and proposes constructive recommendations
for VA action. But most importantly, in our view, GAO advises that
``[s]ome of the daunting challenges facing FRCs and the program are
beyond the capability of the program's leadership to resolve.'' The
issues that GAO identifies may appear daunting, but to fail to resolve
them is to compromise this critical program's effectiveness and to fail
our warriors. We welcome this hearing as an important step toward that
needed resolution.
In essence, GAO highlights critical problems that VA alone cannot
rectify, including--
The lack of a DoD data system that readily and
systematically identifies those servicemembers who are severely
wounded, ill, or injured, and whose medical conditions are highly
likely to prevent their return to duty and also likely to result in
medical separation from the military, namely those who may be
considered for enrollment into the program;
Overlap between DoD and VA case-management and care-
coordination programs that compromises effective coordination--the core
mission of the FRC program--resulting in duplication of effort, waste,
confusion for enrollees and families, and failures to take needed
action based on a mistaken belief that another was assisting the
servicemember;
DoD and VA data-system incompatibility that impedes
sharing basic information; and
Inconsistency in DoD facilities providing FRCs needed
work space, equipment and technology support, despite memoranda of
agreement calling for such support.
We commend GAO for identifying these problems, but are disappointed
that its report did not go further and offer recommendations for a more
substantial DoD role in addressing them. GAO did recognize that the FRC
program was jointly developed by DoD and VA. But since the program is
staffed by VA, operated by VA, and headquartered in VA, it is too often
seen as simply a VA program, rather than a joint DoD-VA undertaking.
This must change for the benefit of those the program is intended to
serve.
An Inter-Departmental Solution
The two departments each share a deep obligation to severely
wounded warriors and their families, but the reality is that they do
not now share full responsibility for the FRC program. With its
critical role in ensuring that severely wounded warriors experience a
seamless transition, the FRC program suffers from such troubling
interdepartmental gaps that an interdepartmental solution should at
least be on the table for discussion. We would go further. WWP
recommends a structural change in the program's governance--
specifically, we propose establishment of an interdepartmental FRC
program office. We offer this recommendation not because we are
critical of VA, but in recognition of the inherent limitations of the
current structure and the overarching obligation owed these warriors
and their families. The concept of a DoD-VA program office is neither
novel nor unprecedented.\2\ While different structural solutions could
be pursued, we foresee continued difficulties for the program, and most
importantly our warriors, unless fundamental changes are brought about
that establish truly shared responsibility.
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\2\ Section 1635 of NDAA 2008 mandated establishment of a DoD/VA
Interagency Program Office (IPO) to act as a single point of
accountability for the department's development of electronic record
systems.
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Referrals for an FRC Assignment: A Broken Process
One of the many issues that GAO identified particularly underscores
how important it is that the FRC program become a truly joint
enterprise. GAO aptly recognizes the importance of identifying all who
could benefit from having an FRC. But the report confirms that
individual service departments are not uniformly referring severely and
catastrophically wounded warriors to the FRC program for assignment, or
are doing so at much too late a point in the transition process. To
illustrate, one of the service departments routinely assigns even the
most severely wounded warriors a Recovery Care Coordinator (RCC), but
makes no FRC referral. Another service department does not necessarily
even assign wounded warriors an RCC let alone an FRC, apparently
deeming that the support provided at warrior transition units meets
care-coordination needs. It is difficult to reconcile service-
department practices that defer referral of a severely wounded warrior
until that individual has retired with a longstanding DoD policy or
with the DoD-VA understanding under which the FRC program was
established. The DoD policy makes it clear that ``all category 3
servicemembers shall be enrolled in the FRCP [Federal Recovery
Coordination Program] and shall be assigned an FRC [Federal Recovery
Coordinator] and an RT [recovery team].'' \3\ The policy instructs
further that the Federal Recovery Coordinator is to coordinate with the
recovery care coordinator and recovery team to ensure the needs of the
servicemember and his or her family are identified and addressed.
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\3\ Department of Defense Instruction (DoDI) Number 1300.24,
``Recovery Coordination Program (RCP),'' Enclosure 4, sec. 2.d.
(December 1, 2009).
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While we are not proponents of blind adherence to policy for its
own sake, the care-coordination policy developed jointly by VA and DoD
to implement the care-coordination provisions of the National Defense
Authorization Act of 2008 is sound. That policy furthers the
fundamental goal of ensuring that wounded warriors have a seamless
transition from DoD to VA that best meets their needs, rather than
furthering the interests of one department or another. Appropriately
implemented, the policy also helps minimize confusion on the part of
wounded warriors regarding the roles of those working on their behalf.
Rather than advancing seamless transition, individual service
department practices that defer referral for a possible FRC assignment
until a severely wounded warrior has retired tend to frustrate
realization of the goals the program was developed to achieve.
One might ask, what difference does it make whether a wounded
warrior has a ``Recovery Care Coordinator,'' a ``Federal Care
Coordinator,'' or some other assistance? In fact, the differences are
real and substantial.
The VA-DoD policy recognizes the importance of providing a Federal
care coordinator for a warrior who has a severe or catastrophic injury
or illness, is highly unlikely to return to duty, and is most likely to
be medically separated. Given the complexity of care and transitional
needs of those with severe or catastrophic wounds, warriors and their
families may be eligible for and need assistance not only from military
treatment facilities and the TRICARE program, but from the Veterans
Health Administration, the Veterans Benefits Administration, the Social
Security Administration, and Medicare. (As the GAO report recognizes,
``FRCs are intended to be care coordinators whose planning,
coordination, monitoring and problem-resolution activities encompass
both health services and benefits provided through DoD, VA, other
Federal agencies, States, and the private sector.'') It is critical
that a Federal coordinator have the depth of experience, training, and
authority to navigate these multiple care/benefits systems. In contrast
to those demanding requirements for an FRC, neither warrior transition
unit staff nor recovery care coordinators (RCCs)--who are to assist
servicemembers whose injuries are not deemed likely to result in a need
for medical separation\4\--have the training, let alone the authority,
to help coordinate care and other needs outside the military system.
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\4\ DoDI 1300.24, Enclosure 4, sec. 2.a.
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Resolving this referral problem is gravely important: failing to
make a referral for an FRC until severely wounded servicemembers retire
can mean delay in their recovery, rehabilitation and re-integration.
These are the very kinds of problems that sparked the call for a
seamless transition, and it is alarming that they should remain
unresolved.
Practices that defer referrals for an FRC until the servicemember
retires seem to reflect a fundamental lack of understanding of the
purpose of the FRC program. At a recent DoD-sponsored summit on care
coordination, Service program personnel repeatedly referred to FRC
services as ``bringing in the VA.'' Rather than being seen--and
marginalized--as a ``VA program,'' the FRC program should be operated
as a joint, integrated effort aimed at coordinating Federal care and
services. What should be a seamless, coordinated undertaking is too
often the opposite, as illustrated by the fact that rather than having
a single recovery plan, warriors may find themselves with multiple
``comprehensive recovery care plans.''
Given the very substantial inter-departmental problems GAO
identified, it is striking that its recommendations were directed only
to VA. As such, the report tends to reinforce the unfortunate
impression that the Department of Defense has no responsibility for
this program. Indeed, DoD's March 4th response to the report (appendix
II)--coming after nearly a decade of war and years since Congress
directed the Departments to ensure seamless recovery-care
coordination--does not seem to reflect any sense of urgency or
commitment to action. Rather, in a one-sentence comment, the DoD
response states that ``a Joint DoD/VA Committee has been formed to
study how to combine or integrate recovery care coordination efforts
for wounded, ill, and injured servicemembers, veterans, and their
families.'' (Emphasis added.) We urge the Subcommittee to consider
GAO's work a starting point, but not necessarily the final word on
these issues.
Finally, WWP has also heard concerns from a number of wounded
warriors and their caregivers regarding lack of communication between
FRCs and their clients. While some are frustrated at not having heard
from an FRC, or don't think to initiate a call, FRCs are often working
on their behalf behind the scenes. WWP recommends that the program
establish clear expectations regarding the frequency and means of
communication to ensure that there is common understanding.
In closing, we urge the Committee to work with the Armed Services
Committee to ensure that the departments move beyond ``study,'' and
jointly take on and resolve the problems that impede full realization
of this program's vital mission. Given the importance of this program
to severely wounded warriors, it is critical that both departments
fully support it. We believe shared governance would best achieve that
objective, and legislation may well be necessary to accomplish that.
Wounded Warrior Project would be pleased to work further with the
Subcommittee to realize in full the goals of this important program.